Provider Demographics
NPI:1508979493
Name:SIROTT, MICHAEL JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JUSTIN
Last Name:SIROTT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10772
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-0772
Mailing Address - Country:US
Mailing Address - Phone:509-846-3930
Mailing Address - Fax:509-288-4269
Practice Address - Street 1:902 ENGH RD
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9473
Practice Address - Country:US
Practice Address - Phone:509-846-3930
Practice Address - Fax:509-288-4269
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA 3806152W00000X
ID103000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1508979493Medicaid