Basic Information
Provider Information
NPI: 1063556215
EntityType: 2
ReplacementNPI:  
OrganizationName: MICHIGAN EYE INSTITUTE OPTICAL
LastName:  
FirstName:  
MiddleName:  
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NameSuffix:  
Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 4499 TOWN CENTER PKWY
Address2:  
City: FLINT
State: MI
PostalCode: 485323425
CountryCode: US
TelephoneNumber: 8107337111
FaxNumber: 8107337141
Practice Location
Address1: 4499 TOWN CENTER PKWY
Address2:  
City: FLINT
State: MI
PostalCode: 485323425
CountryCode: US
TelephoneNumber: 8107337111
FaxNumber: 8107337141
Other Information
ProviderEnumerationDate: 02/19/2007
LastUpdateDate: 10/09/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DISKIN
AuthorizedOfficialFirstName: JEFFREY
AuthorizedOfficialMiddleName: A
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8107337111
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X  Y193400000X SINGLE SPECIALTY GROUPEye and Vision Services ProvidersOptometrist 

No ID Information.


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