Provider Demographics
NPI:1285693598
Name:DE FALCO, MIGUEL (OD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:DE FALCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 JENNIFER RD STE D
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4170
Mailing Address - Country:US
Mailing Address - Phone:410-224-0021
Mailing Address - Fax:410-224-2098
Practice Address - Street 1:169 JENNIFER RD STE D
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-224-0021
Practice Address - Fax:410-224-2098
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4014152W00000X
MDTA2546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621106200Medicaid
FLU7266WOtherPTAN
FL621106201Medicaid
FLU7266WOtherPTAN