Provider Demographics
NPI:1215197587
Name:BARUCH, KATHRYN ANNE (OD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:BARUCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2201
Mailing Address - Country:US
Mailing Address - Phone:248-541-4200
Mailing Address - Fax:
Practice Address - Street 1:621 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2201
Practice Address - Country:US
Practice Address - Phone:248-541-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist