Provider Demographics
NPI:1407883416
Name:DEVRIES, FREDRIC CARL (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:CARL
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 BYRON STATION DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9458
Mailing Address - Country:US
Mailing Address - Phone:616-583-0404
Mailing Address - Fax:616-583-0405
Practice Address - Street 1:3050 IVANREST AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1400
Practice Address - Country:US
Practice Address - Phone:616-538-0150
Practice Address - Fax:616-538-3954
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002219152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16540Medicaid
MI0D16540OtherPRIORITY HEALTH
MI0D16540OtherPRIORITY HEALTH
MI0D16540Medicaid