Provider Demographics
NPI:1225126345
Name:BRONSON, AIMEE (OD)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:
Last Name:BRONSON
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 1:692 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1306
Mailing Address - Country:US
Mailing Address - Phone:616-455-2525
Mailing Address - Fax:616-455-9135
Practice Address - Street 1:6680 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7834
Practice Address - Country:US
Practice Address - Phone:616-455-2525
Practice Address - Fax:616-455-9135
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003997152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI410043795OtherRAILROAD MEDICARE
OD11398OtherBCBS CEC GROUP
MI2587297Medicaid
OD11398OtherBCBS CEC GROUP
MI410043795OtherRAILROAD MEDICARE