Provider Demographics
NPI:1104994532
Name:LINDAHL, WILLIAM JERRY (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JERRY
Last Name:LINDAHL
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 1:26771 W 12 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1539
Mailing Address - Country:US
Mailing Address - Phone:248-263-4900
Mailing Address - Fax:248-263-4903
Practice Address - Street 1:26771 W 12 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1539
Practice Address - Country:US
Practice Address - Phone:248-263-4900
Practice Address - Fax:248-263-4903
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5088773Medicaid
MI900F367240OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI5088773Medicaid
MIU21255Medicare UPIN