Provider Demographics
NPI:1902966773
Name:DRAEGER, TERRANCE L (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:L
Last Name:DRAEGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1353
Mailing Address - Country:US
Mailing Address - Phone:616-842-0008
Mailing Address - Fax:616-842-0054
Practice Address - Street 1:4 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1353
Practice Address - Country:US
Practice Address - Phone:616-842-0008
Practice Address - Fax:616-842-0054
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION28600Medicare ID - Type UnspecifiedMEDICARE B
MIU62223Medicare UPIN