Provider Demographics
NPI:1083824361
Name:HEBERT, MICHELLE M (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:HEBERT
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 1:995 N HIGHWAY A1A
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2940
Mailing Address - Country:US
Mailing Address - Phone:321-961-3503
Mailing Address - Fax:
Practice Address - Street 1:1101 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1604
Practice Address - Country:US
Practice Address - Phone:386-760-1890
Practice Address - Fax:386-760-3223
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3701152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36065OtherBCBS FL
FLAE457ZMedicare PIN