Provider Demographics
NPI:1316058860
Name:LISTENBERGER, MICHEL DALE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHEL
Middle Name:DALE
Last Name:LISTENBERGER
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 1:1248 HUFF AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-9509
Mailing Address - Country:US
Mailing Address - Phone:269-683-4040
Mailing Address - Fax:269-683-7565
Practice Address - Street 1:9 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2846
Practice Address - Country:US
Practice Address - Phone:269-683-4040
Practice Address - Fax:269-683-7565
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4325005Medicaid
N24860001Medicare ID - Type Unspecified
MI4325005Medicaid