Healthcare Provider Details

I. General information

NPI: 1437204815
Provider Name (Legal Business Name): AMY CRISSMAN HEAD O.D., F.A.A.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY ADAMEC CRISSMAN O.D., F.A.A.O.

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD STE 12
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

1149 HILL LINE TRL
BLOOMFIELD HILLS MI
48301-2132
US

V. Phone/Fax

Practice location:
  • Phone: 248-220-6438
  • Fax:
Mailing address:
  • Phone: 248-225-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number4901003852
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003852
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: