Provider Demographics
NPI:1922187673
Name:JONASSEN, MICHAEL EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:JONASSEN
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 1:44 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1123
Mailing Address - Country:US
Mailing Address - Phone:231-873-2575
Mailing Address - Fax:231-873-2593
Practice Address - Street 1:44 S STATE ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1123
Practice Address - Country:US
Practice Address - Phone:231-873-2575
Practice Address - Fax:231-873-2593
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780001Medicare PIN