Provider Demographics
NPI:1598913097
Name:BLOOMFIELD OPTICAL STUDIOS, PC
Entity Type:Organization
Organization Name:BLOOMFIELD OPTICAL STUDIOS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:VERGOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-647-1166
Mailing Address - Street 1:79 W LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2747
Mailing Address - Country:US
Mailing Address - Phone:248-647-1166
Mailing Address - Fax:248-647-5375
Practice Address - Street 1:79 W LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2747
Practice Address - Country:US
Practice Address - Phone:248-647-1166
Practice Address - Fax:248-647-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty