Provider Demographics
NPI:1952518748
Name:SUBURBAN OPTOMETRICS ASSOC P C
Entity type:Organization
Organization Name:SUBURBAN OPTOMETRICS ASSOC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACOBI
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FCOVD
Authorized Official - Phone:734-525-8170
Mailing Address - Street 1:32415 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3039
Mailing Address - Country:US
Mailing Address - Phone:734-525-8170
Mailing Address - Fax:734-525-0726
Practice Address - Street 1:32415 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-3039
Practice Address - Country:US
Practice Address - Phone:734-525-8170
Practice Address - Fax:734-525-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004024152W00000X
MI4901003184152W00000X, 152WL0500X
MI4901003208152WV0400X, 152W00000X
MI4901004851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4309851Medicaid
MI2603194Medicaid
MIU25782Medicare UPIN
MI4309851Medicaid
MI0377500001Medicare NSC
MIU78443Medicare UPIN
MI0Q27636Medicare ID - Type Unspecified