Provider Demographics
NPI:1013992155
Name:SLOUGH RUNSTROM, JULIE (OD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:SLOUGH RUNSTROM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S AIRPORT RD W
Mailing Address - Street 2:#146
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8117
Mailing Address - Country:US
Mailing Address - Phone:231-941-7788
Mailing Address - Fax:231-941-0893
Practice Address - Street 1:3200 S AIRPORT RD W
Practice Address - Street 2:#146
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8117
Practice Address - Country:US
Practice Address - Phone:231-941-7788
Practice Address - Fax:231-941-0893
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJR003108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3278509Medicaid
MI3278509Medicaid
T97005Medicare UPIN