Healthcare Provider Details

I. General information

NPI: 1578506796
Provider Name (Legal Business Name): MICHAEL MATTHEW MERLENBACH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MAPLEWOOD COMMONS DR MERLENBACH EYECARE, P.C.
MAPLEWOOD MO
63143-1005
US

IV. Provider business mailing address

2757 WHITECREEK LN
IMPERIAL MO
63052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-1734
  • Fax: 314-781-0056
Mailing address:
  • Phone: 636-461-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2000169300
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: