Provider Demographics
NPI:1073734224
Name:FERENCE, MARYJO (OD)
Entity Type:Individual
Prefix:MRS
First Name:MARYJO
Middle Name:
Last Name:FERENCE
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 1:2550 S TELEGRAPH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0951
Mailing Address - Country:US
Mailing Address - Phone:248-258-9000
Mailing Address - Fax:248-499-6372
Practice Address - Street 1:2550 S TELEGRAPH RD STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0951
Practice Address - Country:US
Practice Address - Phone:248-258-9000
Practice Address - Fax:248-499-6372
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3960-35152W00000X
MI4901003317152WP0200X, 152W00000X
IDODP-100639152W00000X
PAOEG004118152W00000X
NH1096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU09850Medicare UPIN