Provider Demographics
NPI:1972816023
Name:MARY H ESPY OD PC
Entity Type:Organization
Organization Name:MARY H ESPY OD PC
Other - Org Name:DELTAVISION OPTICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ESPY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-814-5527
Mailing Address - Street 1:2325 SWANS CV
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3006
Mailing Address - Country:US
Mailing Address - Phone:810-814-5527
Mailing Address - Fax:
Practice Address - Street 1:G3541 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1235
Practice Address - Country:US
Practice Address - Phone:810-732-8610
Practice Address - Fax:810-732-6831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B505850OtherBCBS
11839337OtherCAQH
MI4445165Medicaid
P60754OtherBLUE CARE NETWORK
MIU58235Medicare UPIN
MIU58235Medicare UPIN
11839337OtherCAQH