Provider Demographics
NPI:1033159348
Name:COON, KIERSTEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIERSTEN
Middle Name:
Last Name:COON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIERSTEN
Other - Middle Name:
Other - Last Name:DUMLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 MONROE CENTER ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 MONROE CENTER ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2802
Practice Address - Country:US
Practice Address - Phone:616-459-0641
Practice Address - Fax:616-459-0621
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004219152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4599036Medicaid
MI900D114840OtherBCBS PIN NUMBER
MI5474550001OtherADMINASTAR SUPPLY #
MI5474550001OtherADMINASTAR SUPPLY #
MIP19680002Medicare ID - Type Unspecified