Provider Demographics
NPI:1770866840
Name:CHISM, MICHAEL T (OPTOMETRY STUDENT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:CHISM
Suffix:
Gender:M
Credentials:OPTOMETRY STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5924 S 1475 W
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5380
Mailing Address - Country:US
Mailing Address - Phone:909-631-7188
Mailing Address - Fax:
Practice Address - Street 1:6344 S 900 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-2439
Practice Address - Country:US
Practice Address - Phone:801-892-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program