Provider Demographics
NPI:1023175841
Name:WEISER, FRED E (OD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:E
Last Name:WEISER
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 1:519 N PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3442
Mailing Address - Country:US
Mailing Address - Phone:248-624-1707
Mailing Address - Fax:248-624-0203
Practice Address - Street 1:519 N PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3442
Practice Address - Country:US
Practice Address - Phone:248-624-1707
Practice Address - Fax:248-624-0203
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023175841Medicaid
MI1751648Medicaid
MI941751648Medicaid
MI1751648Medicaid
MI0552360001Medicare NSC
MI1023175841Medicaid
MI0F36675Medicare PIN
MIT33466Medicare UPIN