Healthcare Provider Details

I. General information

NPI: 1639138670
Provider Name (Legal Business Name): MICHAEL J DUFFY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAIN ST
EUREKA KS
67045-1315
US

IV. Provider business mailing address

501 N MAIN ST
EUREKA KS
67045-1315
US

V. Phone/Fax

Practice location:
  • Phone: 620-583-6471
  • Fax:
Mailing address:
  • Phone: 620-583-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1119-3
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: