Provider Demographics
NPI:1134196496
Name:EALOVEGA, ANDREW JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:EALOVEGA
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 1:217 W SHELDON
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170
Mailing Address - Country:US
Mailing Address - Phone:734-453-4870
Mailing Address - Fax:734-453-2849
Practice Address - Street 1:217 W SHELDON
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-453-4870
Practice Address - Fax:734-453-2849
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH27901Medicare ID - Type Unspecified
U73319Medicare UPIN