Provider Demographics
NPI:1598750416
Name:DOARNBERGER, LYNNETTE GAY (OD)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:GAY
Last Name:DOARNBERGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 BROADMOOR AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-8180
Mailing Address - Country:US
Mailing Address - Phone:616-534-4953
Mailing Address - Fax:
Practice Address - Street 1:3230 BROADMOOR AVE SE STE A
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-8180
Practice Address - Country:US
Practice Address - Phone:616-534-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2024-10-07
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
MI4901003563152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901003563OtherSTATE LICENSE NUMBER
MIU31656Medicare UPIN