Provider Demographics
NPI:1366735201
Name:KODITEK, MICHAEL EDWARD (OD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:KODITEK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 KEYES ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5956
Mailing Address - Country:US
Mailing Address - Phone:303-833-1056
Mailing Address - Fax:303-833-1057
Practice Address - Street 1:5900 KEYES ST STE 101
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80504-5956
Practice Address - Country:US
Practice Address - Phone:303-833-1056
Practice Address - Fax:303-833-1057
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2850152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist