Provider Demographics
NPI:1457452021
Name:MEDICAL CENTER OPHTHALMOLOGY ASSOC PC
Entity Type:Organization
Organization Name:MEDICAL CENTER OPHTHALMOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:313-831-4090
Mailing Address - Street 1:4727 ST ANTOINE ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-831-4090
Mailing Address - Fax:313-831-4089
Practice Address - Street 1:4727 ST ANTOINE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-831-4090
Practice Address - Fax:313-831-4089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDW031072207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty