Provider Demographics
NPI:1417135922
Name:MEERNIK, MARY TERESE (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESE
Last Name:MEERNIK
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 1:872 MUNSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3638
Mailing Address - Country:US
Mailing Address - Phone:231-947-1690
Mailing Address - Fax:231-947-1692
Practice Address - Street 1:872 MUNSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3638
Practice Address - Country:US
Practice Address - Phone:231-947-1690
Practice Address - Fax:231-947-1692
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7079623Medicaid
MI7079623Medicaid