Provider Demographics
NPI:1639162233
Name:DEFLONTY, JOHNNY L (OD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:L
Last Name:DEFLONTY
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:GREAT LAKES EYE INSTITUTE
Mailing Address - Street 2:2393 SCHUST RD
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-793-9132
Practice Address - Street 1:GREAT LAKES EYE INSTITUTE
Practice Address - Street 2:2393 SCHUST RD
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-793-9132
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002489152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901002489OtherLICENSE #
MI4618893Medicaid
MI4901002489OtherLICENSE #