Provider Demographics
NPI:1235149725
Name:M.D. OPTICAL, WARREN LTD.
Entity Type:Organization
Organization Name:M.D. OPTICAL, WARREN LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:DERR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-852-3636
Mailing Address - Street 1:375 BARCLAY CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4511
Mailing Address - Country:US
Mailing Address - Phone:248-852-3636
Mailing Address - Fax:248-852-3631
Practice Address - Street 1:30051 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3124
Practice Address - Country:US
Practice Address - Phone:248-852-3636
Practice Address - Fax:248-852-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180E012100OtherBLUE CROSS BLUE SHIELD
MI1324420001Medicare NSC