Provider Demographics
NPI:1861015489
Name:JABER, NIKITA S (OD)
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:S
Last Name:JABER
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 1:5120 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2049
Mailing Address - Country:US
Mailing Address - Phone:313-414-2449
Mailing Address - Fax:
Practice Address - Street 1:644 FULTON ST W STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5309
Practice Address - Country:US
Practice Address - Phone:616-465-5503
Practice Address - Fax:616-777-5221
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist