Healthcare Provider Details

I. General information

NPI: 1972812428
Provider Name (Legal Business Name): MICHAEL LESSLY OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S US HIGHWAY 1 UNIT #B-2
JUPITER FL
33477-5132
US

IV. Provider business mailing address

103 S US HIGHWAY 1 UNIT #B-2
JUPITER FL
33477-5132
US

V. Phone/Fax

Practice location:
  • Phone: 561-685-8177
  • Fax: 561-746-3268
Mailing address:
  • Phone: 561-685-8177
  • Fax: 561-746-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC3355
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC3355
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC3355
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC3355
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3355
License Number StateFL

VIII. Authorized Official

Name: VICTORIA MAGGIULLI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 561-685-8177