Provider Demographics
NPI:1922559384
Name:JOHN, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JOHN
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:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-0066
Mailing Address - Country:US
Mailing Address - Phone:320-556-3521
Mailing Address - Fax:
Practice Address - Street 1:1639 ANDERSON AVE.
Practice Address - Street 2:
Practice Address - City:BOCK
Practice Address - State:MN
Practice Address - Zip Code:56313
Practice Address - Country:US
Practice Address - Phone:320-556-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2357152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist