Provider Demographics
NPI:1003804378
Name:GREGORY D POPOWITZ PC
Entity Type:Organization
Organization Name:GREGORY D POPOWITZ PC
Other - Org Name:DELTAVISION OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DARRYL
Authorized Official - Last Name:POPOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-381-2000
Mailing Address - Street 1:2333 JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3541
Mailing Address - Country:US
Mailing Address - Phone:517-381-2000
Mailing Address - Fax:517-381-2006
Practice Address - Street 1:2333 JOLLY RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3541
Practice Address - Country:US
Practice Address - Phone:517-381-2000
Practice Address - Fax:517-381-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI203456Medicaid
MIOC36852OtherBCBSM
MI200000002542Medicaid
MI200000002541Medicaid
MI253368Medicaid
MIOC36852OtherBCBSM
MI200000002541Medicaid
MI1031830001Medicare NSC