Provider Demographics
NPI:1891007688
Name:BLEW, MICHELLE LAUREN ZICKEL (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LAUREN ZICKEL
Last Name:BLEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LAUREN
Other - Last Name:ZICKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:183 PORT RD STE B
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-7735
Mailing Address - Country:US
Mailing Address - Phone:207-216-9937
Mailing Address - Fax:207-216-9939
Practice Address - Street 1:183 PORT RD STE B
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7735
Practice Address - Country:US
Practice Address - Phone:207-216-9937
Practice Address - Fax:207-216-9939
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1048207W00000X, 152W00000X
IL046010377152W00000X
MA4902152W00000X
PAOEG002586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology