Provider Demographics
NPI:1598874109
Name:POPHAM, PHILLIP C (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:C
Last Name:POPHAM
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 1:6444 WOODBURNE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9476
Mailing Address - Country:US
Mailing Address - Phone:810-694-2237
Mailing Address - Fax:
Practice Address - Street 1:G-4190 E. COURT ST.
Practice Address - Street 2:#877
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1718
Practice Address - Country:US
Practice Address - Phone:810-743-4400
Practice Address - Fax:810-743-2740
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930153Medicare PIN
MIU27868Medicare UPIN
MIOB567857-90-2Medicare ID - Type Unspecified
MIN34040065Medicare PIN