Provider Demographics
NPI:1760540363
Name:HIENEMAN, VON SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:VON
Middle Name:SCOTT
Last Name:HIENEMAN
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 1:6739 FULTON ST E
Mailing Address - Street 2:STE. A-20
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8138
Mailing Address - Country:US
Mailing Address - Phone:616-676-2015
Mailing Address - Fax:616-676-2011
Practice Address - Street 1:6739 FULTON ST E
Practice Address - Street 2:STE A-20
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8138
Practice Address - Country:US
Practice Address - Phone:616-676-2015
Practice Address - Fax:616-676-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI90 OD 166250OtherBCBS
MI383455751OtherVSP IDENTIFIER
MI20235OtherSPECTERA
MI4540404Medicaid
MI38-3455751OtherEYEMED
MIOM91600Medicare PIN
MI90 OD 166250OtherBCBS
MIU78049Medicare UPIN