Healthcare Provider Details

I. General information

NPI: 1770079808
Provider Name (Legal Business Name): KATHIE HUANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2018
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4225 CHRYSLER DR APT A
DETROIT MI
48201-0008
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax:
Mailing address:
  • Phone: 415-939-5596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: