Provider Demographics
NPI:1023690757
Name:MUTTER, MARK WAYNE II (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:MUTTER
Suffix:II
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 1:700 W KENT AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6772
Mailing Address - Country:US
Mailing Address - Phone:406-541-3937
Mailing Address - Fax:406-541-3811
Practice Address - Street 1:700 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6772
Practice Address - Country:US
Practice Address - Phone:406-541-3937
Practice Address - Fax:406-541-3811
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist