Healthcare Provider Details

I. General information

NPI: 1063610517
Provider Name (Legal Business Name): MICHELLE L FRYE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W WAYNE ST
FORT WAYNE IN
46802-3976
US

IV. Provider business mailing address

902 W WAYNE ST
FORT WAYNE IN
46802-3976
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-0942
  • Fax:
Mailing address:
  • Phone: 260-422-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number18003461A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18003461A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number18003461A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003461A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: