Provider Demographics
NPI:1477640845
Name:AGNONE, PETER M (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:AGNONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11225 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1285
Mailing Address - Country:US
Mailing Address - Phone:810-694-3937
Mailing Address - Fax:810-694-9876
Practice Address - Street 1:11225 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1285
Practice Address - Country:US
Practice Address - Phone:810-694-3937
Practice Address - Fax:810-694-9876
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0995464OtherHEALTHPLUS OF MICHIGAN
900B511570OtherBLUE CROSS BLUE SHIELD MI
MI944505380Medicaid
1012177OtherMCLAREN HEALTH PLAN
16441OtherM-CARE