Provider Demographics
NPI:1437204815
Name:HEAD, AMY CRISSMAN (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:CRISSMAN
Last Name:HEAD
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:ADAMEC
Other - Last Name:CRISSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD, FAAO
Mailing Address - Street 1:1149 HILL LINE TRL
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2132
Mailing Address - Country:US
Mailing Address - Phone:248-225-8161
Mailing Address - Fax:
Practice Address - Street 1:31815 SOUTHFIELD RD STE 12
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-220-6438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003852152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F310020OtherBCBS PROVIDER CODE
MI383145055OtherTAX ID
MI900F310020OtherBCBS PROVIDER CODE
MIU70963Medicare UPIN