Provider Demographics
NPI:1447255914
Name:HUIZENGA, ROBERT C (O D)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:HUIZENGA
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:7673 GEORGETOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8101
Practice Address - Country:US
Practice Address - Phone:616-457-2020
Practice Address - Fax:616-457-4043
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5330000171152W00000X
MI4901002647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI152W0000XOtherTAXONOMY
MI0375270001Medicare NSC
MIT33592Medicare UPIN