Provider Demographics
NPI:1750391603
Name:PITKO, MARIE E (OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:E
Last Name:PITKO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42524 HAYES STE. #300
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP.
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-228-9740
Mailing Address - Fax:586-286-1507
Practice Address - Street 1:42524 HAYES RD STE 300
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3643
Practice Address - Country:US
Practice Address - Phone:586-228-9740
Practice Address - Fax:586-228-1507
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540E00320OtherBCBS VISION
MI2656278Medicaid
MIB08000205Medicare NSC