Provider Demographics
NPI:1124040282
Name:HART, GERALD E (OD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:E
Last Name:HART
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 1:2575 S VAN DYKE RD
Mailing Address - Street 2:STE 104 PO BOX 398
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-9787
Mailing Address - Country:US
Mailing Address - Phone:989-635-1500
Mailing Address - Fax:
Practice Address - Street 1:2575 S VAN DYKE RD
Practice Address - Street 2:STE 104
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-9787
Practice Address - Country:US
Practice Address - Phone:989-635-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C26505Medicare PIN
MI0278270001Medicare NSC