Provider Demographics
NPI:1245328202
Name:CORDELL, DONALD O (OD)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:O
Last Name:CORDELL
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 1:3031 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3046
Mailing Address - Country:US
Mailing Address - Phone:313-871-0220
Mailing Address - Fax:
Practice Address - Street 1:2424 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1010
Practice Address - Country:US
Practice Address - Phone:313-366-5100
Practice Address - Fax:313-366-2246
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3324479Medicaid
MI3324479Medicaid
MIU21472Medicare UPIN