Provider Demographics
NPI:1285609842
Name:CISNEROS, MICHELLE LEE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2260 LINDA AVE. STE. 201
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763
Mailing Address - Country:US
Mailing Address - Phone:432-333-3937
Mailing Address - Fax:432-337-3937
Practice Address - Street 1:2260 LINDA AVE. STE. 201
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763
Practice Address - Country:US
Practice Address - Phone:432-333-3937
Practice Address - Fax:432-337-3937
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06583TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176264301Medicaid
TX8D8296Medicare ID - Type Unspecified
TX176264301Medicaid