Provider Demographics
NPI:1679729685
Name:RATZENBERGER, TATJANA ALEXANDRA JASMIN (OD)
Entity Type:Individual
Prefix:DR
First Name:TATJANA
Middle Name:ALEXANDRA JASMIN
Last Name:RATZENBERGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5856
Mailing Address - Country:US
Mailing Address - Phone:248-544-3290
Mailing Address - Fax:248-528-4040
Practice Address - Street 1:735 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5856
Practice Address - Country:US
Practice Address - Phone:248-544-3290
Practice Address - Fax:248-528-4040
Is Sole Proprietor?:No
Enumeration Date:2008-08-10
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004456152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679729685Medicaid
M30440076Medicare PIN