Provider Demographics
NPI:1962547299
Name:CONGLETON, ERROL RAYMOND (OD)
Entity type:Individual
Prefix:
First Name:ERROL
Middle Name:RAYMOND
Last Name:CONGLETON
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 1:509 S SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4516
Mailing Address - Country:US
Mailing Address - Phone:989-835-2020
Mailing Address - Fax:989-835-6192
Practice Address - Street 1:509 S SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4516
Practice Address - Country:US
Practice Address - Phone:989-835-2020
Practice Address - Fax:989-835-6192
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP4453001Medicare PIN