Provider Demographics
NPI:1720242258
Name:MORTON, MICHAEL KEVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:MORTON
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 1:222 NORTH G STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3219
Mailing Address - Country:US
Mailing Address - Phone:909-885-1134
Mailing Address - Fax:
Practice Address - Street 1:222 N G ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3217
Practice Address - Country:US
Practice Address - Phone:909-885-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG890XMedicare PIN