MEDICARE: DR. ABIGAIL DIANE MADER O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6233	OH

General Provider Information

NPI Number	:	1053759886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ABIGAIL DIANE MADER O.D.

Provider Business Mailing Address
First Line	:	118 CASS AVE
Second Line	:
City	:	MOUNT CLEMENS
State	:	MI
Zip	:	48043-2204
Country	:	US
Telephone Number	:	586-468-7370
Fax Number	:

Provider Business Practice Location Address
First Line	:	4786 RIDGE RD
Second Line	:
City	:	BROOKLYN
State	:	OH
Zip	:	44144-3327
Country	:	US
Telephone Number	:	740-361-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2013
Last Update Date	:	04/05/2022

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