Provider Demographics
NPI:1043249394
Name:MICHITSCH, MARK D (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MICHITSCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3333 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7985
Mailing Address - Country:US
Mailing Address - Phone:614-784-5331
Mailing Address - Fax:775-746-5316
Practice Address - Street 1:9700 SOUTH MCCARRAN BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523
Practice Address - Country:US
Practice Address - Phone:775-827-3937
Practice Address - Fax:775-746-5316
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1043249394Medicaid
U25833Medicare UPIN
VOD278Medicare PIN
NV100510213Medicaid
NVU25833Medicare UPIN