MEDICARE: BENJAMIN MICHALICEK OD

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	3969	WI
2	152W00000X	Optometrist	3802	MN

General Provider Information

NPI Number	:	1396323176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN MICHALICEK OD

Provider Business Mailing Address
First Line	:	272 SNELLING AVE S STE 300
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2829
Country	:	US
Telephone Number	:	651-369-7833
Fax Number	:	651-560-5732

Provider Business Practice Location Address
First Line	:	272 SNELLING AVE S STE 300
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2829
Country	:	US
Telephone Number	:	651-369-7833
Fax Number	:	651-560-5732

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

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	12/12/2025

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