Provider Demographics
NPI:1427146521
Name:GOODFELLOW, LEE R (OD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:R
Last Name:GOODFELLOW
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 1:6680 DIVISION AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7834
Mailing Address - Country:US
Mailing Address - Phone:616-455-2525
Mailing Address - Fax:616-455-9135
Practice Address - Street 1:6680 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7834
Practice Address - Country:US
Practice Address - Phone:616-455-2525
Practice Address - Fax:616-455-9135
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OD16514OtherBCBS
410021740OtherRAILROAD MEDICARE
MI2589040Medicaid
OD16514OtherBCBS
MID17845001Medicare ID - Type Unspecified