Healthcare Provider Details

I. General information

NPI: 1205904570
Provider Name (Legal Business Name): MICHAEL G LESSLY OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 GERMANNA HWY C
LOCUST GROVE VA
22508-2040
US

IV. Provider business mailing address

4207 GERMANNA HWY C
LOCUST GROVE VA
22508-2040
US

V. Phone/Fax

Practice location:
  • Phone: 561-685-8177
  • Fax: 540-972-6788
Mailing address:
  • Phone: 561-685-8177
  • Fax: 540-972-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3355
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618001596
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC3355
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618001596
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC3355
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number0618001596
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC3355
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number0618001596
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC3355
License Number StateFL
# 10
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number06180001596
License Number StateVA

VIII. Authorized Official

Name: MS. VICTORIA M MAGGIULLI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 561-685-8177