Provider Demographics
NPI:1972552289
Name:FLYNN, MICKI MAUREEN (OD)
Entity type:Individual
Prefix:DR
First Name:MICKI
Middle Name:MAUREEN
Last Name:FLYNN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 VINE STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-381-1234
Mailing Address - Fax:715-381-5357
Practice Address - Street 1:2215 VINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-5802
Practice Address - Country:US
Practice Address - Phone:715-381-1234
Practice Address - Fax:715-381-5357
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3002-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U98308Medicare UPIN
00047905Medicare ID - Type Unspecified