Basic Information
| Provider Information | |||||||||
| NPI: | 1003806910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIFANO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12533 WOODPINE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481788177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484866124 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26388 FORD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481272854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137305020 | ||||||||
| FaxNumber: | 3137305027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003561 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3216845 | 05 | MI | MEDICAID |