Organization
PHILLIP A. KOHANOV O.D. PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PHILLIP A. KOHANOV O.D. (OPTOMETRIST)
(810) 985-5600
Entity
Organization
Contact information
Practice address
3833 24TH AVE, FORT GRATIOT, MI 48059-4100
(810) 985-5600
(810) 985-5740
Mailing address
3833 24TH AVE, FORT GRATIOT, MI 48059-4100
(810) 985-5600
(810) 985-5740
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1038350001
REGION B DMERC
—
01
—
900G465140
BLUE CROSS BLUE SHIELD
—
Enumeration date
11/15/2007
Last updated
06/05/2012
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