Provider Demographics
NPI:1447347919
Name:FORD, GINA TERESE (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:TERESE
Last Name:FORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8361 CHARLEVOIX ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3988
Mailing Address - Country:US
Mailing Address - Phone:269-569-0683
Mailing Address - Fax:
Practice Address - Street 1:501 N 9TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6594
Practice Address - Country:US
Practice Address - Phone:269-544-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20782OtherSPECTERA
MI90-0-C9-1227-0OtherBLUE CROSS BLUE SHIELD
MIFO1579300OtherCLARITY VISION
MIOP17590Medicare ID - Type Unspecified