MEDICARE: DR. MICHAEL DESMOND MAIN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3021-035	WI

General Provider Information

NPI Number	:	1386687333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DESMOND MAIN O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	517-223-6780

Provider Business Practice Location Address
First Line	:	1220 PARKWOOD DR
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-5488
Country	:	US
Telephone Number	:	715-421-2111
Fax Number	:	715-421-2123

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	05/24/2021

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