Provider Demographics
NPI:1891103818
Name:BAUER, ADELINE (OD)
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ADELINE
Other - Middle Name:
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4130 BRETON RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-3808
Mailing Address - Country:US
Mailing Address - Phone:616-341-1713
Mailing Address - Fax:616-341-1714
Practice Address - Street 1:4130 BRETON RD SE STE A
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-3808
Practice Address - Country:US
Practice Address - Phone:616-341-1713
Practice Address - Fax:616-341-1714
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004841152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900E476020OtherBLUE CROSS
MI1871510859Medicaid
MI0784610001OtherMEDICARE NSC
MI0784610001OtherMEDICARE NSC