Basic Information
| Provider Information | |||||||||
| NPI: | 1598385247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUJAWSKI | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLISON | ||||||||
| OtherFirstName: | SARAH | ||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 118 CASS AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22561 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | EASTPOINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480212360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635021005 | ||||||||
| FaxNumber: | 5863502104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2020 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901005462 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.