Provider Demographics
NPI:1063438901
Name:ROUNTREE, MICHELLE (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROUNTREE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10360 SW 186 ST #970150
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10360 SW 186 ST #970150
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33197
Practice Address - Country:US
Practice Address - Phone:954-222-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF740OtherMEDICARE PTAN
FL6208622 00Medicaid
FLU97384Medicare UPIN