Provider Demographics
NPI:1528016961
Name:PACK-CUNNINGHAM, NAOMI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:ANN
Last Name:PACK-CUNNINGHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NAOMI
Other - Middle Name:ANN
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:45744 BRYN MAWR RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5430
Mailing Address - Country:US
Mailing Address - Phone:734-454-1701
Mailing Address - Fax:
Practice Address - Street 1:43271 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3340
Practice Address - Country:US
Practice Address - Phone:734-981-8111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003888152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist