Provider Demographics
NPI:1770630444
Name:DEHOOG, BERNARD (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:DEHOOG
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 WESTOVER TER
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-1996
Mailing Address - Country:US
Mailing Address - Phone:336-288-9504
Mailing Address - Fax:336-282-1957
Practice Address - Street 1:1607 WESTOVER TER
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-1996
Practice Address - Country:US
Practice Address - Phone:336-288-9504
Practice Address - Fax:336-282-1957
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC993156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802029Medicaid
NC8802029Medicaid