Healthcare Provider Details

I. General information

NPI: 1508154246
Provider Name (Legal Business Name): NICOLE MARIE BENNETT GDOWSKI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MARIE BENNETT

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 S WESTNEDGE AVE STE 232
PORTAGE MI
49024-3503
US

IV. Provider business mailing address

6650 S WESTNEDGE AVE STE 232
PORTAGE MI
49024-3503
US

V. Phone/Fax

Practice location:
  • Phone: 616-617-0187
  • Fax: 269-743-3720
Mailing address:
  • Phone: 616-617-0187
  • Fax: 269-743-3720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: