Provider Demographics
NPI:1922131259
Name:LIVONIA OPHTHALMOLOGISTS PC
Entity Type:Organization
Organization Name:LIVONIA OPHTHALMOLOGISTS PC
Other - Org Name:LIVONIA OPHTHALMOLOGISTS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUPOVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-522-0800
Mailing Address - Street 1:29927 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3670
Mailing Address - Country:US
Mailing Address - Phone:734-522-0800
Mailing Address - Fax:734-522-1236
Practice Address - Street 1:29927 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3670
Practice Address - Country:US
Practice Address - Phone:734-522-0800
Practice Address - Fax:734-522-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH24256OtherBLUE CROSS GROUP
MI540Q208880OtherBLUE CROSS VISION
MIC0GXQOtherBC SUBMITTER ID
MI0820689OtherMR ADVANTAGE
MI540Q208880OtherBLUE CROSS VISION
MIC0GXQOtherBC SUBMITTER ID
MI0184600001Medicare NSC