Basic Information
| Provider Information | |||||||||
| NPI: | 1790754109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGLEMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1265 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178863937 | ||||||||
| FaxNumber: | 4178861285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178863937 | ||||||||
| FaxNumber: | 4178861285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T02775 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 316901305 | 05 | MO | MEDICAID |