Basic Information
| Provider Information | |||||||||
| NPI: | 1639366354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIESE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10416 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981257402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065176700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10416 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065176700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD00004085 | WA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OD00004085 | 01 | WA | MEDICAL LICENSE | OTHER |