Provider Demographics
NPI:1821024126
Name:KONYNENBELT, STANLEY M (OD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:M
Last Name:KONYNENBELT
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 1:300 S STATE ST
Mailing Address - Street 2:#15
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464
Mailing Address - Country:US
Mailing Address - Phone:616-772-9149
Mailing Address - Fax:616-772-2906
Practice Address - Street 1:300 S STATE ST
Practice Address - Street 2:#15
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464
Practice Address - Country:US
Practice Address - Phone:616-772-9149
Practice Address - Fax:616-772-2906
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G07612002Medicare PIN
MIT33526Medicare UPIN
MI0603840001Medicare NSC