Healthcare Provider Details

I. General information

NPI: 1710728258
Provider Name (Legal Business Name): ALEXA MARIE AYYASH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22371 PONTIAC TRL
SOUTH LYON MI
48178-1658
US

IV. Provider business mailing address

21020 TAFT RD
NORTHVILLE MI
48167-1004
US

V. Phone/Fax

Practice location:
  • Phone: 248-437-7600
  • Fax:
Mailing address:
  • Phone: 248-595-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005797
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: