Provider Demographics
NPI:1629093562
Name:LIZYNESS, JAY PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:PAUL
Last Name:LIZYNESS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-3226
Mailing Address - Fax:313-916-8132
Practice Address - Street 1:655 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1844
Practice Address - Country:US
Practice Address - Phone:248-577-3659
Practice Address - Fax:248-588-9320
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIL698050152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV02129Medicare UPIN