Healthcare Provider Details

I. General information

NPI: 1710470281
Provider Name (Legal Business Name): ETHAN MITCHEL STERN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2018
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 W GANSON ST
JACKSON MI
49202-4240
US

IV. Provider business mailing address

1116 W GANSON ST
JACKSON MI
49202-4240
US

V. Phone/Fax

Practice location:
  • Phone: 877-852-8463
  • Fax:
Mailing address:
  • Phone: 877-852-8463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number338669
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberEMC0009269
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: