Provider Demographics
NPI:1407880883
Name:KORTHALS, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KORTHALS
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 1:422 S PIERCE AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2709
Mailing Address - Country:US
Mailing Address - Phone:641-424-0780
Mailing Address - Fax:641-424-2345
Practice Address - Street 1:422 S PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2709
Practice Address - Country:US
Practice Address - Phone:641-424-0780
Practice Address - Fax:641-424-2345
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5178720001OtherDMERC
IA1204016Medicaid
IA42149949950401OtherTRICARE
IAIA0101OtherJOHN DEERE
IA35096OtherBLUE CROSS & BLUE SHIELD
IAP00135209OtherRR MEDICARE
IA42149949950401OtherTRICARE
IAP00135209OtherRR MEDICARE