MEDICARE: DR. DEBRA E BOURDEAU O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004051	MI

General Provider Information

NPI Number	:	1790764173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBRA E BOURDEAU O.D.

Provider Business Mailing Address
First Line	:	3050 UNION LAKE RD STE 3B
Second Line	:
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48382-4563
Country	:	US
Telephone Number	:	248-360-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 UNION LAKE RD
Second Line	:	STE 3B
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48382-4509
Country	:	US
Telephone Number	:	248-360-4300
Fax Number	:	248-360-4503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	01/14/2016

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