Provider Demographics
NPI:1417935925
Name:GORSLINE, AMANDA B (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:B
Last Name:GORSLINE
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 1:2764 MOYER RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9569
Mailing Address - Country:US
Mailing Address - Phone:517-655-7072
Mailing Address - Fax:
Practice Address - Street 1:1669 HAMILTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1956
Practice Address - Country:US
Practice Address - Phone:517-349-4743
Practice Address - Fax:517-349-0096
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU93967Medicare UPIN