Provider Demographics
NPI:1780675363
Name:HART, JOHN C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:HART
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 ORCHARD LAKE RD
Mailing Address - Street 2:STE 307
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-855-1020
Mailing Address - Fax:248-855-2639
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:STE 307
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-855-1020
Practice Address - Fax:248-855-2639
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058202207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18047Medicare UPIN
ON40420001Medicare ID - Type Unspecified