Healthcare Provider Details

I. General information

NPI: 1225278880
Provider Name (Legal Business Name): PEDIATRIC OPHTHALMOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 09/11/2025
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 CASCADE RD SE
GRAND RAPIDS MI
49546-3707
US

IV. Provider business mailing address

5050 CASCADE RD SE
GRAND RAPIDS MI
49546-3707
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-0866
  • Fax: 616-957-4102
Mailing address:
  • Phone: 616-957-0866
  • Fax: 616-957-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number003979
License Number StateMI

VIII. Authorized Official

Name: MRS. DEBORAH M DROSTE
Title or Position: ADMINISTRATOR
Credential: RN BSN
Phone: 616-957-0866