Provider Demographics
NPI:1043757057
Name:WARDELL, MICHAEL CRAIG (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:WARDELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 24TH ST W STE 8
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-3800
Mailing Address - Country:US
Mailing Address - Phone:406-281-8480
Mailing Address - Fax:
Practice Address - Street 1:1005 24TH ST W STE 8
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-3800
Practice Address - Country:US
Practice Address - Phone:406-281-8180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2937152WC0802X, 152WV0400X, 152W00000X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics