Healthcare Provider Details

I. General information

NPI: 1083653497
Provider Name (Legal Business Name): MICHAEL L SUSSEX OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 S CENTREVILLE RD
STURGIS MI
49091
US

IV. Provider business mailing address

350 MARSHALL ST
COLDWATER MI
49036
US

V. Phone/Fax

Practice location:
  • Phone: 269-651-2960
  • Fax: 269-657-4333
Mailing address:
  • Phone: 517-278-6303
  • Fax: 517-279-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL L SUSSEX
Title or Position: PRESIDENT OWNER
Credential: OD
Phone: 269-651-2960