Provider Demographics
NPI:1093704850
Name:DELTAVISION OPTICAL CENTER PC
Entity Type:Organization
Organization Name:DELTAVISION OPTICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:FOON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-732-8610
Mailing Address - Street 1:G3541 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1235
Mailing Address - Country:US
Mailing Address - Phone:810-732-8610
Mailing Address - Fax:810-732-6813
Practice Address - Street 1:G3541 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1235
Practice Address - Country:US
Practice Address - Phone:810-732-8610
Practice Address - Fax:810-732-6813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI230370OtherNVA
MI1004305OtherMCLAREN MEDICAID
MI31986OtherCOLE
MI7333067OtherAETNA
MI27671OtherSPECTERA
MI31986OtherCOLE
MI=========OtherTAX ID
MI27671OtherSPECTERA