Provider Demographics
NPI:1518977230
Name:WIERINGA, JON R (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:WIERINGA
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 1:2112 EAST PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-949-8500
Mailing Address - Fax:616-949-2878
Practice Address - Street 1:2112 EAST PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-949-8500
Practice Address - Fax:616-949-2878
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518977230Medicaid
MI900H115190OtherBCBS MICHIGAN
MI1518977230Medicaid