Provider Demographics
NPI:1588759930
Name:LEMON, KERMIT L (OD)
Entity type:Individual
Prefix:DR
First Name:KERMIT
Middle Name:L
Last Name:LEMON
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 1:425 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895
Mailing Address - Country:US
Mailing Address - Phone:517-655-2037
Mailing Address - Fax:517-655-1983
Practice Address - Street 1:425 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895
Practice Address - Country:US
Practice Address - Phone:517-655-2037
Practice Address - Fax:517-655-1983
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5093639Medicaid
MI0C36357OtherBCBSM
MI200000025234OtherPHP
MIKL002677OtherSTATE LICENCE NUMBER
MI0727670001Medicare NSC
MI0M01930018Medicare PIN
MI0C36357OtherBCBSM
MI0C36564Medicare ID - Type Unspecified