Healthcare Provider Details

I. General information

NPI: 1336257989
Provider Name (Legal Business Name): MICHEL PAUL KISH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7347 BELL CREEK RD STE 200
MECHANICSVILLE VA
23111-3504
US

IV. Provider business mailing address

PO BOX 1290
FOREST VA
24551-1290
US

V. Phone/Fax

Practice location:
  • Phone: 804-746-5245
  • Fax:
Mailing address:
  • Phone: 434-385-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000967
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: