Provider Demographics
NPI:1700899143
Name:REXINE, MICHAEL KENNETH (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:REXINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257-1314
Mailing Address - Country:US
Mailing Address - Phone:701-786-2666
Mailing Address - Fax:701-786-2292
Practice Address - Street 1:32 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257-1314
Practice Address - Country:US
Practice Address - Phone:701-786-2666
Practice Address - Fax:701-786-2292
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60602Medicaid
NDN24924Medicare PIN
ND60602Medicaid