Provider Demographics
NPI:1487634929
Name:ABDELLA, JOHN PHILIP (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILIP
Last Name:ABDELLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4185
Mailing Address - Country:US
Mailing Address - Phone:810-732-0202
Mailing Address - Fax:810-732-4018
Practice Address - Street 1:1356 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4185
Practice Address - Country:US
Practice Address - Phone:810-732-0202
Practice Address - Fax:810-732-4018
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002484152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU53790Medicare UPIN
MIOM23760Medicare ID - Type Unspecified