Healthcare Provider Details

I. General information

NPI: 1073831822
Provider Name (Legal Business Name): RANDY WATSKY ODPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8709 W GRAND RIVER AVE SUITE A
BRIGHTON MI
48116-2923
US

IV. Provider business mailing address

8709 W GRAND RIVER AVE SUITE A
BRIGHTON MI
48116-2923
US

V. Phone/Fax

Practice location:
  • Phone: 810-220-4499
  • Fax:
Mailing address:
  • Phone: 810-220-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDY GREGG WATSKY
Title or Position: OPTOMETRIST
Credential: OD
Phone: 810-220-4499