Provider Demographics
NPI:1346388915
Name:CANDREVA, MICHAEL A (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:CANDREVA
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:N 10 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538
Mailing Address - Country:US
Mailing Address - Phone:701-854-8248
Mailing Address - Fax:701-854-7411
Practice Address - Street 1:10 N RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-8248
Practice Address - Fax:701-854-7411
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2018-08-17
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-07
Provider Licenses
StateLicense IDTaxonomies
COCO1796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5540010Medicaid