Provider Demographics
NPI:1992763049
Name:POWERS, MICHAEL ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:POWERS
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 1:3546 ST JOHNS BLUFF RD S
Mailing Address - Street 2:UNIT 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-996-1533
Mailing Address - Fax:904-996-1535
Practice Address - Street 1:3546 ST JOHNS BLUFF RD S
Practice Address - Street 2:UNIT 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-996-1533
Practice Address - Fax:904-996-1535
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043609673OtherTAX IDENTIFICATION NUMBER
FL20725OtherBCBS
FL620752900Medicaid
FL20725OtherBCBS
FLE8326ZMedicare PIN
FL620752900Medicaid