Provider Demographics
NPI:1073300786
Name:MITTICA, MICHELLE S (ABOC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:MITTICA
Suffix:
Gender:
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4847
Mailing Address - Country:US
Mailing Address - Phone:575-388-4464
Mailing Address - Fax:
Practice Address - Street 1:604 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4847
Practice Address - Country:US
Practice Address - Phone:575-388-4464
Practice Address - Fax:575-388-2014
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician