Provider Demographics
NPI:1912083759
Name:WEST MICHIGAN OPHTHALMOLOGY, PC
Entity Type:Organization
Organization Name:WEST MICHIGAN OPHTHALMOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-737-9378
Mailing Address - Street 1:1150 E SHERMAN BLVD
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1871
Mailing Address - Country:US
Mailing Address - Phone:231-737-9378
Mailing Address - Fax:231-737-1023
Practice Address - Street 1:1150 E SHERMAN BLVD
Practice Address - Street 2:SUITE 1500
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1871
Practice Address - Country:US
Practice Address - Phone:231-737-9378
Practice Address - Fax:231-737-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079878207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1806111162OtherBCBSM PIN
MI104960267Medicaid
MI104960267Medicaid