Provider Demographics
NPI:1780783381
Name:POGGIOLO, JOHN CHRISTOPHER (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:POGGIOLO
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 1:28532 SCHEONHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088
Mailing Address - Country:US
Mailing Address - Phone:586-777-0060
Mailing Address - Fax:586-777-1501
Practice Address - Street 1:28532 SCHEONHERR RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088
Practice Address - Country:US
Practice Address - Phone:586-777-0060
Practice Address - Fax:586-777-1501
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97999Medicare UPIN
MION82550Medicare ID - Type Unspecified