Provider Demographics
NPI:1790720225
Name:DUDOVITZ, JENNIFER COOPER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:COOPER
Last Name:DUDOVITZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10494 LUDLOW AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1524
Mailing Address - Country:US
Mailing Address - Phone:248-543-9486
Mailing Address - Fax:
Practice Address - Street 1:28655 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4105
Practice Address - Country:US
Practice Address - Phone:586-751-0400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003920152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06683OtherBCBS