Provider Demographics
NPI:1124181763
Name:EAST DETROIT OPHTHALMOLOGY P.C.
Entity Type:Organization
Organization Name:EAST DETROIT OPHTHALMOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLOMBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-778-4400
Mailing Address - Street 1:22835 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2073
Mailing Address - Country:US
Mailing Address - Phone:586-778-4400
Mailing Address - Fax:586-778-3642
Practice Address - Street 1:22835 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2073
Practice Address - Country:US
Practice Address - Phone:586-778-4400
Practice Address - Fax:586-778-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJC026758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3456128Medicaid
MIOEO7713OtherBLUE CROSS BLUE SHIELD
MI3456128Medicaid
MI0179220001Medicare NSC
MI=========OtherTAX ID#
MIA75096Medicare UPIN