Basic Information
| Provider Information | |||||||||
| NPI: | 1003804378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREGORY D POPOWITZ PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DELTAVISION OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 JOLLY RD | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173812000 | ||||||||
| FaxNumber: | 5173812006 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 JOLLY RD | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173812000 | ||||||||
| FaxNumber: | 5173812006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POPOWITZ | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | DARRYL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5173812000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901003607 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 203456 | 05 | MI | MEDICAID | OC36852 | 01 | MI | BCBSM | OTHER | 200000002542 | 05 | MI | MEDICAID | 200000002541 | 05 | MI | MEDICAID | 253368 | 05 | MI | MEDICAID |