Provider Demographics
NPI:1821119645
Name:BELLENBAUM, WILLIAM RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RICHARD
Last Name:BELLENBAUM
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 1:1982 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1736
Mailing Address - Country:US
Mailing Address - Phone:517-349-2050
Mailing Address - Fax:517-349-7209
Practice Address - Street 1:1982 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1736
Practice Address - Country:US
Practice Address - Phone:517-349-2050
Practice Address - Fax:517-349-7209
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002723152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34040101,N26930191Medicare PIN