Provider Demographics
NPI:1083612162
Name:CRANK, JAY J (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:J
Last Name:CRANK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6748 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7032
Mailing Address - Country:US
Mailing Address - Phone:616-275-2020
Mailing Address - Fax:
Practice Address - Street 1:6748 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7032
Practice Address - Country:US
Practice Address - Phone:616-275-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301003678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D16525OtherBCBS
MI180024098OtherMEDICARE RR
MI3192010Medicaid
MI900D16525OtherBCBS
MI3192010Medicaid
MI0364980001Medicare NSC