Provider Demographics
NPI:1730292210
Name:AUSTHOF, MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:AUSTHOF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2640 CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7930
Mailing Address - Country:US
Mailing Address - Phone:231-933-7195
Mailing Address - Fax:231-933-7197
Practice Address - Street 1:2640 CROSSING CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7930
Practice Address - Country:US
Practice Address - Phone:231-933-7195
Practice Address - Fax:231-933-7197
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI90-0-B8-1061-0OtherBLUE CROSS BLUE SHIELD
MI90-0-B8-1061-0OtherBLUE CROSS BLUE SHIELD
MIU73692Medicare UPIN