MEDICARE: ANDREA MOTT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004653	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900B10059	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1316235237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MOTT O.D.

Provider Business Mailing Address
First Line	:	1015 S LINCOLN RD
Second Line	:
City	:	ESCANABA
State	:	MI
Zip	:	49829-2100
Country	:	US
Telephone Number	:	906-786-5181
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 S LINCOLN RD
Second Line	:
City	:	ESCANABA
State	:	MI
Zip	:	49829-2100
Country	:	US
Telephone Number	:	906-786-5181
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2011
Last Update Date	:	06/22/2020

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