Provider Demographics
NPI:1679519805
Name:BOTNER, MICHELLE LEIDENIX (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIDENIX
Last Name:BOTNER
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2774
Mailing Address - Country:US
Mailing Address - Phone:406-860-2020
Mailing Address - Fax:406-862-2385
Practice Address - Street 1:509 E 6TH ST
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2774
Practice Address - Country:US
Practice Address - Phone:406-862-2020
Practice Address - Fax:406-862-2385
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND 511152W00000X
MT1562152W00000X
MTMT1562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1679519805Medicaid
ND60433Medicaid