Provider Demographics
NPI:1841974037
Name:EWALD, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:EWALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURE
Other - Middle Name:
Other - Last Name:WEIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15500 SILVER PKWY APT 202
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12606 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1892
Practice Address - Country:US
Practice Address - Phone:810-694-3652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist