Provider Demographics
NPI:1205927175
Name:MONSON, MICHAEL MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARK
Last Name:MONSON
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 1:30 S 1970 E
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-4420
Mailing Address - Country:US
Mailing Address - Phone:406-565-8298
Mailing Address - Fax:
Practice Address - Street 1:345 W 600 S STE 300
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2268
Practice Address - Country:US
Practice Address - Phone:435-654-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT757 OPT152W00000X
UT12983357-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0483072Medicaid
MT28091OtherBLUE CROSS BLUE SHIELD MT
MTDB9976OtherRR MCR GROUP # (ODPC)
WY121304100Medicaid
AKOD 075 MTMedicaid