Provider Demographics
NPI:1306063532
Name:EBELS, CALVIN DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:DANIEL
Last Name:EBELS
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 1:4339 PULTE DR
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435
Mailing Address - Country:US
Mailing Address - Phone:616-677-1784
Mailing Address - Fax:
Practice Address - Street 1:SEARS OPTICAL
Practice Address - Street 2:3622 RIVERTOWN PKWY
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-257-0049
Practice Address - Fax:616-257-0054
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU80117Medicare UPIN
MI0N10540Medicare ID - Type Unspecified