Provider Demographics
NPI:1790773646
Name:FOX, MARIE LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LOUISE
Last Name:FOX
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 1:6101 NEWPORT RD
Mailing Address - Street 2:STE A
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9233
Mailing Address - Country:US
Mailing Address - Phone:269-382-6500
Mailing Address - Fax:269-382-2286
Practice Address - Street 1:6101 NEWPORT RD
Practice Address - Street 2:STE A
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9233
Practice Address - Country:US
Practice Address - Phone:269-382-6500
Practice Address - Fax:269-382-2286
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381734365OtherTAX ID
MI4901004197OtherLICENSE
MI17800OtherSPECTERA
MI900C947460OtherBCBS
MI2230146OtherUHC,IBA,PHP
MI4536386Medicaid
MI381734365OtherTAX ID
MI4901004197OtherLICENSE
MI4536386Medicaid