Healthcare Provider Details

I. General information

NPI: 1588402077
Provider Name (Legal Business Name): TITIANA GORGES OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 JOHN R RD
TROY MI
48083-5856
US

IV. Provider business mailing address

735 JOHN R RD
TROY MI
48083-5856
US

V. Phone/Fax

Practice location:
  • Phone: 248-951-0000
  • Fax:
Mailing address:
  • Phone: 248-951-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: