Healthcare Provider Details

I. General information

NPI: 1568655355
Provider Name (Legal Business Name): MICHAEL E JONASSEN, O.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S STATE ST
HART MI
49420-1123
US

IV. Provider business mailing address

44 S STATE ST
HART MI
49420-1123
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-2575
  • Fax: 231-873-2593
Mailing address:
  • Phone: 231-873-2575
  • Fax: 231-873-2593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003163
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4901003163
License Number StateMI

VIII. Authorized Official

Name: MICHAEL E JONASSEN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 231-873-2575