Healthcare Provider Details

I. General information

NPI: 1043249394
Provider Name (Legal Business Name): MARK D MICHITSCH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 SOUTH MCCARRAN BLVD
RENO NV
89523
US

IV. Provider business mailing address

3333 QUALITY DR
RANCHO CORDOVA CA
95670-7985
US

V. Phone/Fax

Practice location:
  • Phone: 775-827-3937
  • Fax: 775-746-5316
Mailing address:
  • Phone: 614-784-5331
  • Fax: 775-746-5316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number278
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: