Provider Demographics
NPI:1588742548
Name:SAMU SHOULDICE, JULIE LYNN (OD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:LYNN
Last Name:SAMU SHOULDICE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:LYNN
Other - Last Name:SAMU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6494 LINK BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-9784
Mailing Address - Country:US
Mailing Address - Phone:313-539-2020
Mailing Address - Fax:
Practice Address - Street 1:6494 LINK BLVD
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9784
Practice Address - Country:US
Practice Address - Phone:313-539-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0585020001OtherADMINASTAR
MI4236737Medicaid
MI0N16830OtherMEDICARE PLUS BLUE
MI4100442401OtherRAILROAD MEDICARE
MI900F965090OtherBCBS
MIU81692Medicare UPIN
MI0585020001OtherADMINASTAR
MI4100442401OtherRAILROAD MEDICARE