Provider Demographics
NPI:1689656837
Name:OPPENHEIM, GARY S (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:OPPENHEIM
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 1:33308 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3124
Mailing Address - Country:US
Mailing Address - Phone:248-474-5125
Mailing Address - Fax:248-474-4854
Practice Address - Street 1:33308 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3124
Practice Address - Country:US
Practice Address - Phone:248-474-5125
Practice Address - Fax:248-474-4854
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI317837094Medicaid
MI3178370Medicaid
MI900F366860OtherBCBSM
MIP00810638Medicare PIN
MI900F366860OtherBCBSM
MI3178370Medicaid
1037080002Medicare NSC