Healthcare Provider Details

I. General information

NPI: 1295343549
Provider Name (Legal Business Name): ANDREW HEPNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7021 S WESTNEDGE AVE
PORTAGE MI
49002-4206
US

IV. Provider business mailing address

9950 W P AVE
KALAMAZOO MI
49009-4404
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-0534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005479
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: