Provider Demographics
NPI:1518013606
Name:HONHOLT, BRUCE EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:HONHOLT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:5150 NORTHLAND DRIVE NE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-364-4099
Practice Address - Fax:636-364-1138
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T33058Medicare UPIN