Healthcare Provider Details

I. General information

NPI: 1568520716
Provider Name (Legal Business Name): JOEL E ENSMINGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2974 28TH ST SE STE A
KENTWOOD MI
49512-1664
US

IV. Provider business mailing address

2718 OLDEPOINTE DR NE
GRAND RAPIDS MI
49525-3021
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-2120
  • Fax: 616-949-9015
Mailing address:
  • Phone: 616-363-3708
  • Fax: 616-949-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002617
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: