Provider Demographics
NPI:1275720013
Name:GARY S. OPPENHEIM, O.D., P.C.
Entity Type:Organization
Organization Name:GARY S. OPPENHEIM, O.D., P.C.
Other - Org Name:EYE SPY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:OPPENHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-474-5125
Mailing Address - Street 1:33308 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3124
Mailing Address - Country:US
Mailing Address - Phone:248-474-5125
Mailing Address - Fax:248-474-5484
Practice Address - Street 1:33308 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3124
Practice Address - Country:US
Practice Address - Phone:248-474-5125
Practice Address - Fax:248-474-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F34230OtherBCBSM
MI900F366860OtherBCBSM
MI3178370Medicaid
MI1037080001Medicare NSC
MI0N86460Medicare PIN
MI900F366860OtherBCBSM
MI0F34230OtherBCBSM