Provider Demographics
NPI:1699941807
Name:MICHALKO, MICHELLE VIRGENE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VIRGENE
Last Name:MICHALKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-1343
Mailing Address - Country:US
Mailing Address - Phone:607-734-4898
Mailing Address - Fax:
Practice Address - Street 1:380 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-1343
Practice Address - Country:US
Practice Address - Phone:607-734-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005605156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician