Basic Information
| Provider Information | |||||||||
| NPI: | 1285847509 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID E. DURYEA, O.D., P.C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED EYECARE & CONTACT LENS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 BRADY ROAD | ||||||||
| Address2: | |||||||||
| City: | CHESANING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898457050 | ||||||||
| FaxNumber: | 9898452036 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 BRADY ROAD | ||||||||
| Address2: | |||||||||
| City: | CHESANING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898457050 | ||||||||
| FaxNumber: | 9898452036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DURYEA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ERIC | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9898457050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 94505795 | 05 | MI | MEDICAID | 944316613 | 05 | MI | MEDICAID |