Provider Demographics
NPI:1821124165
Name:SCHULTZE, GORDON DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:DALE
Last Name:SCHULTZE
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 1:597 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-7994
Mailing Address - Country:US
Mailing Address - Phone:616-457-0760
Mailing Address - Fax:616-457-0762
Practice Address - Street 1:597 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7994
Practice Address - Country:US
Practice Address - Phone:616-457-0760
Practice Address - Fax:616-457-0762
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33525Medicare UPIN
MION96950-001Medicare ID - Type Unspecified