Provider Demographics
NPI:1851584643
Name:JOHN J DEGROOT OD PC
Entity Type:Organization
Organization Name:JOHN J DEGROOT OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:231-347-3298
Mailing Address - Street 1:614 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2724
Mailing Address - Country:US
Mailing Address - Phone:231-347-3298
Mailing Address - Fax:231-347-0564
Practice Address - Street 1:614 HOWARD ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2724
Practice Address - Country:US
Practice Address - Phone:231-347-3298
Practice Address - Fax:231-347-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJD002327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN80540Medicare UPIN