Provider Demographics
NPI:1972674992
Name:FAMILY OPTOMETRY ASSOCIATES, PC
Entity Type:Organization
Organization Name:FAMILY OPTOMETRY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-740-0222
Mailing Address - Street 1:2950 E WATTLES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-7008
Mailing Address - Country:US
Mailing Address - Phone:248-740-0222
Mailing Address - Fax:248-689-0123
Practice Address - Street 1:2950 E WATTLES RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-7008
Practice Address - Country:US
Practice Address - Phone:248-740-0222
Practice Address - Fax:248-689-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F36621OtherBLUE CROSS BLUE SHEILD
MI1876473Medicaid
MI$$$$$$$$$OtherSSN
MI900F36621OtherBLUE CROSS BLUE SHEILD
MI1876473Medicaid