Provider Demographics
NPI:1568506111
Name:MILLARD, MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:MILLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BEDNAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1610
Mailing Address - Country:US
Mailing Address - Phone:219-836-1738
Mailing Address - Fax:219-836-2822
Practice Address - Street 1:630 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1610
Practice Address - Country:US
Practice Address - Phone:219-836-1738
Practice Address - Fax:219-836-2822
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002899AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0407090001OtherDME MAC
IN388370GMedicare PIN
IN0407090001OtherDME MAC
INU68480Medicare UPIN