Healthcare Provider Details

I. General information

NPI: 1740073238
Provider Name (Legal Business Name): ETHAN JARED DUPUIS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S ADAMS RD STE 201
BIRMINGHAM MI
48009-7008
US

IV. Provider business mailing address

17228 COVE DR
NORTHVILLE MI
48168-2288
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-8060
  • Fax: 248-644-5081
Mailing address:
  • Phone: 810-908-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: