Provider Demographics
NPI:1396792016
Name:VARANELLI, JEFFREY RICHARD (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:VARANELLI
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 1:29245 RYAN ROAD
Mailing Address - Street 2:#100 SIMONE EYE CENTER
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-1421
Mailing Address - Country:US
Mailing Address - Phone:586-558-2981
Mailing Address - Fax:586-558-8838
Practice Address - Street 1:29245 RYAN ROAD
Practice Address - Street 2:#100 SIMONE EYE CENTER
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-558-2981
Practice Address - Fax:586-558-8838
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003935152W00000X
MI16207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900N834800OtherBCBSM
MI0N83480Medicare UPIN
MI900N834800OtherBCBSM
MI900N834800OtherBCBSM