Provider Demographics
NPI:1174576904
Name:MICHAELS, JUSTIN B (OD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:B
Last Name:MICHAELS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:M
Other - Last Name:BOBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23002 LAKE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6801
Mailing Address - Country:US
Mailing Address - Phone:949-454-1064
Mailing Address - Fax:949-454-4111
Practice Address - Street 1:23002 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6801
Practice Address - Country:US
Practice Address - Phone:949-454-1064
Practice Address - Fax:949-454-4111
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist