Basic Information
Provider Information | |||||||||
NPI: | 1992790703 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MESAROS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2393 SCHUST RD | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486031334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897932820 | ||||||||
FaxNumber: | 9897551463 | ||||||||
Practice Location | |||||||||
Address1: | 2393 SCHUST RD | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486031334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897932820 | ||||||||
FaxNumber: | 9897551463 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2005 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 4301026069 | MI | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 0G30089 | 01 |   | BCBSM GROUP ID | OTHER | 1427090976 | 01 |   | GROUP NPI | OTHER | 0G36036 | 01 |   | MEDICARE GROUP ID | OTHER | 4156171 | 05 | MI |   | MEDICAID | CA3610 | 01 |   | RAILROAD MEDICARE | OTHER |