Provider Demographics
NPI:1801806856
Name:STANISZEWSKI, TODD EDWARD (OD)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:EDWARD
Last Name:STANISZEWSKI
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 1:5874 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3358
Mailing Address - Country:US
Mailing Address - Phone:248-620-1100
Mailing Address - Fax:248-620-1196
Practice Address - Street 1:5874 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3358
Practice Address - Country:US
Practice Address - Phone:248-620-1100
Practice Address - Fax:248-620-1196
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T53704Medicare UPIN
OM41550Medicare ID - Type Unspecified
MI1190300001Medicare NSC