Provider Demographics
NPI:1629057187
Name:OCCHIETTI, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:OCCHIETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 SOUTH STEPHENSON AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-779-9870
Mailing Address - Fax:906-779-5888
Practice Address - Street 1:1711 SOUTH STEPHENSON AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801
Practice Address - Country:US
Practice Address - Phone:906-776-5250
Practice Address - Fax:906-228-0217
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMO063234207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
383105579OtherTAX ID
WI32564300Medicaid
MI4318832Medicaid
MI300220077OtherBLUE CROSS
MI300220077OtherBLUE CROSS
MI0N30910Medicare PIN
H00175Medicare UPIN
WI32564300Medicaid