Healthcare Provider Details

I. General information

NPI: 1124004171
Provider Name (Legal Business Name): MICHAEL JOSEPH HITTENMILLER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

IV. Provider business mailing address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

V. Phone/Fax

Practice location:
  • Phone: 563-323-2020
  • Fax: 563-328-5694
Mailing address:
  • Phone: 563-323-2020
  • Fax: 563-328-5694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01711
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: