Provider Demographics
NPI:1659412302
Name:CONNICK, ERIC (OD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:CONNICK
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 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:616-844-6079
Practice Address - Street 1:2279 S AIRPORT RD W
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4713
Practice Address - Country:US
Practice Address - Phone:231-932-1520
Practice Address - Fax:231-932-1552
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32620012Medicare PIN
MI0P32620Medicare PIN
MIU37094Medicare UPIN