Provider Demographics
NPI:1508154246
Name:GDOWSKI, NICOLE MARIE BENNETT (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE BENNETT
Last Name:GDOWSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:597 BALDWIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7994
Mailing Address - Country:US
Mailing Address - Phone:616-617-0187
Mailing Address - Fax:
Practice Address - Street 1:597 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7994
Practice Address - Country:US
Practice Address - Phone:616-457-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34040118Medicare PIN
MIN26930223Medicare PIN