Provider Demographics
NPI:1124004171
Name:HITTENMILLER, MICHAEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:HITTENMILLER
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 1:777 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-328-5694
Practice Address - Street 1:777 TANGLEFOOT LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1650
Practice Address - Country:US
Practice Address - Phone:563-323-2020
Practice Address - Fax:563-328-5694
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0740183OtherIA GROUP MEDICAID
IA0028225Medicaid
IAI4200Medicare PIN
IA0028225Medicaid