Provider Demographics
NPI:1609044452
Name:GERALD E HART OD
Entity Type:Organization
Organization Name:GERALD E HART OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-635-1500
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-0398
Mailing Address - Country:US
Mailing Address - Phone:989-635-1500
Mailing Address - Fax:989-635-3937
Practice Address - Street 1:STE 104
Practice Address - Street 2:2575 S VAN DYKE RD
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-9787
Practice Address - Country:US
Practice Address - Phone:989-635-1500
Practice Address - Fax:989-635-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0278270001Medicare NSC
MIT32858Medicare UPIN