Healthcare Provider Details

I. General information

NPI: 1093979742
Provider Name (Legal Business Name): MARC L AUSTHOF OD EYE CARE SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 CROSSING CIR
TRAVERSE CITY MI
49684-7930
US

IV. Provider business mailing address

2640 CROSSING CIR
TRAVERSE CITY MI
49684-7930
US

V. Phone/Fax

Practice location:
  • Phone: 231-933-7195
  • Fax: 231-933-7197
Mailing address:
  • Phone: 231-933-7195
  • Fax: 231-933-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003842
License Number StateMI

VIII. Authorized Official

Name: DR. MARC LOUIS AUSTHOF
Title or Position: PRESIDENT
Credential: O.D.
Phone: 231-933-7195