Provider Demographics
NPI:1063586410
Name:MIDWEST OPTOMETRY GROUP, PLLC
Entity type:Organization
Organization Name:MIDWEST OPTOMETRY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:517-278-8248
Mailing Address - Street 1:335 W BARNHART RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-9263
Mailing Address - Country:US
Mailing Address - Phone:517-278-8248
Mailing Address - Fax:
Practice Address - Street 1:1500 S CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8245
Practice Address - Country:US
Practice Address - Phone:269-651-4523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-19
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P15110Medicare ID - Type Unspecified