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General NPI Number Information
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NPI Number | 1780907246
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Entity Type | Individual
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Provider Name | BRIAN EDWARD KONYNENBELT O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/11/2010
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Last Update Date | 01/15/2013
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Provider Practice Location Address
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Address Line | 300 S STATE ST SUITE 15
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City | ZEELAND
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State | MI
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Zip | 49464-1678
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Country | US
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Telephone | 616-772-9149
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Fax | 616-772-2906
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Provider Business Mailing Address
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Address Line | 300 S STATE ST STE 15
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City | ZEELAND
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State | MI
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Zip | 49464-1678
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Country | US
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Telephone | 616-772-9149
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Fax | 616-772-2906
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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 | 4901004535
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 49010044535
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License Number State | MI
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