Provider Demographics
NPI:1962592758
Name:FREDRIC C DEVRIES OD PC
Entity type:Organization
Organization Name:FREDRIC C DEVRIES OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:616-538-0150
Mailing Address - Street 1:2711 BYRON STATION DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9458
Mailing Address - Country:US
Mailing Address - Phone:616-583-0404
Mailing Address - Fax:616-583-0405
Practice Address - Street 1:3050 IVANREST AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1400
Practice Address - Country:US
Practice Address - Phone:616-538-0150
Practice Address - Fax:616-538-3954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002219152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16540Medicaid
MI0D16540OtherPRIORITY HEALTH
MIT33039Medicare UPIN
MIP38430001Medicare PIN