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General NPI Number Information
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NPI Number | 1053759886
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Entity Type | Individual
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Provider Name | ABIGAIL DIANE MADER O.D.
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Gender | Female
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Dates
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Enumeration Date | 06/14/2013
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 4786 RIDGE RD
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City | BROOKLYN
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State | OH
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Zip | 44144-3327
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Country | US
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Telephone | 740-361-7700
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Fax |
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Provider Business Mailing Address
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Address Line | 118 CASS AVE
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City | MOUNT CLEMENS
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State | MI
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Zip | 48043-2204
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Country | US
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Telephone | 586-468-7370
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 6233
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License Number State | OH
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