Provider Demographics
NPI:1093199010
Name:BETKA, MIKAELA JO (OD)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:JO
Last Name:BETKA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CLEVELAND AVE
Mailing Address - Street 2:#307
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-4300
Mailing Address - Country:US
Mailing Address - Phone:402-806-0604
Mailing Address - Fax:
Practice Address - Street 1:2904 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2437
Practice Address - Country:US
Practice Address - Phone:269-983-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL844588152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist