Provider Demographics
NPI:1003965831
Name:SIPPALA, CAROLINE J (OD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:J
Last Name:SIPPALA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18900 MICHIGAN AVE
Mailing Address - Street 2:FAIRLANE TOWNE CENTER
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3929
Mailing Address - Country:US
Mailing Address - Phone:519-796-9290
Mailing Address - Fax:
Practice Address - Street 1:27380 NOVI RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3414
Practice Address - Country:US
Practice Address - Phone:248-344-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930017Medicare ID - Type Unspecified
MIU50775Medicare UPIN