Healthcare Provider Details

I. General information

NPI: 1285609842
Provider Name (Legal Business Name): MICHELLE LEE CISNEROS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LEE GARZA OD

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 LINDA AVE. STE. 201
ODESSA TX
79763
US

IV. Provider business mailing address

2260 LINDA AVE. STE. 201
ODESSA TX
79763
US

V. Phone/Fax

Practice location:
  • Phone: 432-333-3937
  • Fax: 432-337-3937
Mailing address:
  • Phone: 432-333-3937
  • Fax: 432-337-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number06583TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: