Provider Demographics
NPI:1699005165
Name:IRWIN, ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:IRWIN
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 1:46852 REGISTRY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1689
Mailing Address - Country:US
Mailing Address - Phone:734-416-0152
Mailing Address - Fax:
Practice Address - Street 1:2100 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2250
Practice Address - Country:US
Practice Address - Phone:313-382-8044
Practice Address - Fax:313-389-3099
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist