Provider Demographics
NPI:1023182573
Name:BURGESS, CHRISTOPHER A (OD, MPH)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:M
Credentials:OD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44038 PARKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2117
Mailing Address - Country:US
Mailing Address - Phone:734-459-4805
Mailing Address - Fax:
Practice Address - Street 1:750 STEWART RD
Practice Address - Street 2:SUITE #2
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4291
Practice Address - Country:US
Practice Address - Phone:734-242-8630
Practice Address - Fax:734-242-8666
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICB002739OtherCOMERCIAL BCBS MI VISION
MICB002739OtherCOMERCIAL BCBS MI VISION