Basic Information
| Provider Information | |||||||||
| NPI: | 1235312570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYANDOTTE OPTICAL,P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 BIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481925915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342825030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 BIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481925915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342825030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEIN | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 7342825030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 4901002491 | MI | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 900H266940 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |