Provider Demographics
NPI:1164485801
Name:STANDIFORD, FERRIS R (OD)
Entity Type:Individual
Prefix:
First Name:FERRIS
Middle Name:R
Last Name:STANDIFORD
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 1:3412 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4624
Mailing Address - Country:US
Mailing Address - Phone:269-329-5870
Mailing Address - Fax:269-329-5865
Practice Address - Street 1:3412 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4624
Practice Address - Country:US
Practice Address - Phone:269-329-5870
Practice Address - Fax:269-329-5865
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4073524Medicaid
MI4073524Medicaid
0N31700Medicare ID - Type Unspecified