Healthcare Provider Details

I. General information

NPI: 1104994532
Provider Name (Legal Business Name): WILLIAM JERRY LINDAHL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26771 W 12 MILE RD SUITE 100
SOUTHFIELD MI
48034-1539
US

IV. Provider business mailing address

26771 W 12 MILE RD SUITE 100
SOUTHFIELD MI
48034-1539
US

V. Phone/Fax

Practice location:
  • Phone: 248-263-4900
  • Fax: 248-263-4903
Mailing address:
  • Phone: 248-263-4900
  • Fax: 248-263-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901002652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: