Provider Demographics
NPI:1780907246
Name:KONYNENBELT, BRIAN EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
Last Name:KONYNENBELT
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 1:300 S STATE ST STE 15
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1678
Mailing Address - Country:US
Mailing Address - Phone:616-772-9149
Mailing Address - Fax:616-772-2906
Practice Address - Street 1:300 S STATE ST
Practice Address - Street 2:SUITE 15
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1678
Practice Address - Country:US
Practice Address - Phone:616-772-9149
Practice Address - Fax:616-772-2906
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004535152W00000X
MI49010044535152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G076001006Medicare PIN