Healthcare Provider Details

I. General information

NPI: 1699696260
Provider Name (Legal Business Name): MICKENZIE MICHAEL HOWARD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 S COLLEGE AVE STE B
FORT COLLINS CO
80525-1423
US

IV. Provider business mailing address

1820 S COLLEGE AVE STE B
FORT COLLINS CO
80525-1423
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-6360
  • Fax: 970-493-0286
Mailing address:
  • Phone: 970-493-6360
  • Fax: 970-493-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0004236
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: