Provider Demographics
NPI:1659380293
Name:MUTH, DALE W (OD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:W
Last Name:MUTH
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 1:504 W HARRIE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1200
Mailing Address - Country:US
Mailing Address - Phone:906-293-9276
Mailing Address - Fax:906-293-9100
Practice Address - Street 1:504 W HARRIE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1200
Practice Address - Country:US
Practice Address - Phone:906-293-9276
Practice Address - Fax:906-293-9100
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D800030OtherBCBS OF MICHIGAN
MI425582194Medicaid
MI425582194Medicaid
MIOM88190Medicare ID - Type Unspecified