Provider Demographics
NPI:1356497432
Name:ICEBERG, JEFFERY M (OD)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:M
Last Name:ICEBERG
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:3192 S LINDEN RD
Practice Address - Street 2:SUITE B121
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-230-9300
Practice Address - Fax:810-230-1453
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U45530Medicare UPIN