Provider Demographics
NPI:1124098793
Name:NAMETZ, JOHN M (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:NAMETZ
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 1:108 W SAVIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1603
Mailing Address - Country:US
Mailing Address - Phone:616-846-2280
Mailing Address - Fax:616-846-2294
Practice Address - Street 1:108 W SAVIDGE ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1603
Practice Address - Country:US
Practice Address - Phone:616-846-2280
Practice Address - Fax:616-846-2294
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900G065260OtherBC/BS OF MICHIGAN
MI94-5098027Medicaid
MI94-5098027Medicaid
OG06526Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MIT33531Medicare UPIN