Provider Demographics
NPI:1346573987
Name:WEATHERHEAD, LINDSAY MARIE-BASLER (OD)
Entity Type:Individual
Prefix:DR
First Name:LINDSAY
Middle Name:MARIE-BASLER
Last Name:WEATHERHEAD
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 1:1311 MARSHWOOD CT SW
Mailing Address - Street 2:APT. 3A
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9008
Mailing Address - Country:US
Mailing Address - Phone:616-291-3854
Mailing Address - Fax:
Practice Address - Street 1:750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6049
Practice Address - Country:US
Practice Address - Phone:616-949-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOFC40152W00000X
MI4901004516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist