Provider Demographics
NPI:1922002708
Name:GREAT LAKES EYE CARE PC
Entity Type:Organization
Organization Name:GREAT LAKES EYE CARE PC
Other - Org Name:GREAT LAKES EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LOCKE
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-3300
Mailing Address - Street 1:2848 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3352
Mailing Address - Country:US
Mailing Address - Phone:269-428-3300
Mailing Address - Fax:269-428-5005
Practice Address - Street 1:2848 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3352
Practice Address - Country:US
Practice Address - Phone:269-428-3300
Practice Address - Fax:269-428-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046231207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1878128Medicaid
MIA75426Medicare UPIN
MI0321930001Medicare NSC
MI1878128Medicaid