Provider Demographics
NPI:1497836167
Name:CLEARY, DAVID A (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:CLEARY
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 1:133 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1429
Mailing Address - Country:US
Mailing Address - Phone:269-657-7288
Mailing Address - Fax:269-655-9063
Practice Address - Street 1:133 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1429
Practice Address - Country:US
Practice Address - Phone:269-657-7288
Practice Address - Fax:269-655-9063
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33884Medicare UPIN
MI0H07900-002Medicare ID - Type Unspecified