Healthcare Provider Details

I. General information

NPI: 1649226499
Provider Name (Legal Business Name): GENE FONGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MONROE CENTER ST NW
GRAND RAPIDS MI
49503-2802
US

IV. Provider business mailing address

144 MONROE CENTER ST NW
GRAND RAPIDS MI
49503-2802
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-0641
  • Fax: 616-459-0621
Mailing address:
  • Phone: 616-459-0641
  • Fax: 616-459-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4901002505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: