Provider Demographics
NPI:1992795132
Name:VONSEGGERN, JEFFREY ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:VONSEGGERN
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 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:
Practice Address - Street 1:101 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1933
Practice Address - Country:US
Practice Address - Phone:616-754-6300
Practice Address - Fax:616-754-5009
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004210A152W00000X
MI4901003781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI201249427OtherTAX ID
MI900G011510OtherBCBS OF MICHIGAN
MIP55978OtherBCN
MI230541OtherNVA
MI900F111210OtherBCBS OF MICHIGAN
MI202916337OtherTAX ID
MI4634180Medicaid
MIDC1560Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP
MI5189400011Medicare NSC
MIU57963Medicare UPIN
MIP00151228Medicare ID - Type UnspecifiedRAILROAD MEDICARE INDIVID
MI4634180Medicaid