Provider Demographics
NPI:1346407889
Name:DOUGLAS FRASER VISION CENTER
Entity Type:Organization
Organization Name:DOUGLAS FRASER VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-203-1100
Mailing Address - Street 1:38110 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2842
Mailing Address - Country:US
Mailing Address - Phone:734-728-5940
Mailing Address - Fax:
Practice Address - Street 1:38110 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2842
Practice Address - Country:US
Practice Address - Phone:734-728-5940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION55750OtherMEDICARE PROVIDER #