Healthcare Provider Details

I. General information

NPI: 1457007379
Provider Name (Legal Business Name): MICHIGAN OPHTHALMOLOGY SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E 14 MILE RD STE B
CLAWSON MI
48017-2118
US

IV. Provider business mailing address

30150 TELEGRAPH RD STE 271
BINGHAM FARMS MI
48025-4521
US

V. Phone/Fax

Practice location:
  • Phone: 248-589-9500
  • Fax:
Mailing address:
  • Phone: 248-395-5175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY ZWICKER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 248-395-5175