Healthcare Provider Details

I. General information

NPI: 1447766191
Provider Name (Legal Business Name): MICHELE LYNN WURGLICS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 CENTEREACH MALL
CENTEREACH NY
11720-2750
US

IV. Provider business mailing address

1029 BROADWAY
ISLIP NY
11751-1314
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-0402
  • Fax: 631-585-0425
Mailing address:
  • Phone: 631-219-9050
  • Fax: 631-585-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number009956
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: