Basic Information
| Provider Information | |||||||||
| NPI: | 1497743108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32987 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485499080 | ||||||||
| FaxNumber: | 2485494770 | ||||||||
| Practice Location | |||||||||
| Address1: | 32987 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485499080 | ||||||||
| FaxNumber: | 2485494770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 03/04/2011 | ||||||||
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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 | 4901002904 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 941742068 | 05 | MI | MEDICAID | 4901002904 | 01 | MI | OD LICENSE # | OTHER |