Provider Demographics
NPI:1982699294
Name:GARIN, MARK MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MICHAEL
Last Name:GARIN
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 1:43996 WOODWARD AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5028
Mailing Address - Country:US
Mailing Address - Phone:248-332-4544
Mailing Address - Fax:248-332-2716
Practice Address - Street 1:43996 WOODWARD AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5028
Practice Address - Country:US
Practice Address - Phone:248-332-4544
Practice Address - Fax:248-332-2716
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2012-11-30
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MI4901003079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780532Medicaid
MIP07250003OtherMEDICARE PTAN
MIP07250003OtherMEDICARE PTAN