Provider Demographics
NPI:1689970667
Name:COLE, MICHAEL WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:COLE
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 1:981 S MAIN ST STE 220
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6055
Mailing Address - Country:US
Mailing Address - Phone:435-363-2980
Mailing Address - Fax:435-514-0075
Practice Address - Street 1:981 S MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6055
Practice Address - Country:US
Practice Address - Phone:435-363-2980
Practice Address - Fax:435-514-0075
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9413616-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist