=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174545487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA DAVID METZGER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1266 E SHERMAN BLVD
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-739-9009
-----------------------------------------------------
Fax | 231-733-0566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 CHARLOTTE AVE NW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49504-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-735-0703
-----------------------------------------------------
Fax | 616-735-0703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004319
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------