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General NPI Number Information
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NPI Number | 1790720225
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Entity Type | Individual
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Provider Name | JENNIFER COOPER DUDOVITZ O.D.
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Gender | Female
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Dates
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Enumeration Date | 06/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 28655 HOOVER RD
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City | WARREN
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State | MI
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Zip | 48093-4105
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Country | US
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Telephone | 586-751-0400
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Fax |
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Provider Business Mailing Address
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Address Line | 10494 LUDLOW AVE
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City | HUNTINGTON WOODS
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State | MI
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Zip | 48070-1524
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Country | US
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Telephone | 248-543-9486
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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 | 4901003920
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License Number State | MI
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