Provider Demographics
NPI:1720017312
Name:CHADWICK, JEFFREY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:CHADWICK
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 1:325 M-55 EAST
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763
Mailing Address - Country:US
Mailing Address - Phone:989-362-2754
Mailing Address - Fax:989-362-6231
Practice Address - Street 1:325 M-55 EAST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763
Practice Address - Country:US
Practice Address - Phone:989-362-2754
Practice Address - Fax:989-362-6231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3473906Medicaid
MI3473906Medicaid
MI0M61240Medicare ID - Type Unspecified
MI1221170001Medicare NSC