Provider Demographics
NPI:1700912375
Name:FOGEL, BRUCE E (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:FOGEL
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 1:140 MACOMB PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5651
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-468-7682
Practice Address - Street 1:16128 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3338
Practice Address - Country:US
Practice Address - Phone:734-421-2844
Practice Address - Fax:734-421-2878
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4500258Medicaid
MI4109640001Medicare ID - Type Unspecified
MIU24279Medicare UPIN