Provider Demographics
NPI:1821130428
Name:WISMANN, MICHAEL GUY (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GUY
Last Name:WISMANN
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 1:9760 HILLDALE DR
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-2334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8501 W BOWLES AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-9502
Practice Address - Country:US
Practice Address - Phone:303-972-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist