Provider Demographics
NPI:1669485801
Name:KALKOFEN, GREGORY G (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:G
Last Name:KALKOFEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:
Other - Last Name:KALKOFEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:42550 GARFIELD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1644
Mailing Address - Country:US
Mailing Address - Phone:586-263-9708
Mailing Address - Fax:586-263-0280
Practice Address - Street 1:42550 GARFIELD
Practice Address - Street 2:SUITE 101
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1644
Practice Address - Country:US
Practice Address - Phone:586-263-9708
Practice Address - Fax:586-263-0280
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE06315009Medicare PIN
U73331Medicare UPIN
MI0229820002Medicare NSC