Provider Demographics
NPI:1366938771
Name:MITMAN, MARIAH (OD)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:MITMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2330
Mailing Address - Country:US
Mailing Address - Phone:406-363-2020
Mailing Address - Fax:
Practice Address - Street 1:820 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2330
Practice Address - Country:US
Practice Address - Phone:406-363-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1016152W00000X
MT3373152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1366938771Medicaid