Provider Demographics
NPI:1164518106
Name:VAN OPTICAL, P.C.
Entity Type:Organization
Organization Name:VAN OPTICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:VANOTTEREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-649-4978
Mailing Address - Street 1:8850 SALINE MILAN RD
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-8826
Mailing Address - Country:US
Mailing Address - Phone:734-944-4404
Mailing Address - Fax:734-944-3937
Practice Address - Street 1:1601 E US HIGHWAY 223
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-4454
Practice Address - Country:US
Practice Address - Phone:517-265-9883
Practice Address - Fax:517-265-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION30050Medicare ID - Type Unspecified