Provider Demographics
NPI:1174594105
Name:DOLPHIN, BRIAN M (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:DOLPHIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:M
Other - Last Name:DOLPHIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:750 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6049
Mailing Address - Country:US
Mailing Address - Phone:616-949-2600
Mailing Address - Fax:616-365-2076
Practice Address - Street 1:750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6049
Practice Address - Country:US
Practice Address - Phone:616-949-2600
Practice Address - Fax:616-365-2076
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00831511OtherMEDICARE RR
MI0M94220Medicare PIN