Provider Demographics
NPI:1174739932
Name:KORICAN, RENEE MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:MARIE
Last Name:KORICAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:256 CYPRESS TRAIL DR SE
Mailing Address - Street 2:GRAND RAPIDS
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8634
Mailing Address - Country:US
Mailing Address - Phone:616-437-0164
Mailing Address - Fax:616-942-0345
Practice Address - Street 1:6740 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6888
Practice Address - Country:US
Practice Address - Phone:616-942-9888
Practice Address - Fax:616-942-0345
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU52257Medicare UPIN