Provider Demographics
NPI:1336282623
Name:CANFIELD, MARK (OD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:CANFIELD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1965
Mailing Address - Country:US
Mailing Address - Phone:616-754-4696
Mailing Address - Fax:616-754-4697
Practice Address - Street 1:322 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1965
Practice Address - Country:US
Practice Address - Phone:616-754-4696
Practice Address - Fax:616-754-4697
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N91640Medicare ID - Type Unspecified