Provider Demographics
NPI:1730196262
Name:ENGELMAN, MAX HARRIS (OD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:HARRIS
Last Name:ENGELMAN
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 1:1323 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8720
Mailing Address - Country:US
Mailing Address - Phone:231-439-3937
Mailing Address - Fax:231-439-9058
Practice Address - Street 1:1323 SPRING ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8720
Practice Address - Country:US
Practice Address - Phone:231-439-3937
Practice Address - Fax:231-439-9058
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B410480OtherBLUE CROSS
MI3522537Medicaid
MIP50250001OtherMEDICARE WPS
AZZ164110Medicare PIN
AZZ162078Medicare PIN
MI3522537Medicaid
AZZ163012Medicare PIN
AZZ164111Medicare PIN
AZZ164113Medicare PIN
AZZ162076Medicare PIN
MIU31661Medicare UPIN
AZZ162075Medicare PIN
AZZ164114Medicare PIN
AZZ164115Medicare PIN
AZZ164112Medicare PIN
AZZ162077Medicare PIN
MI900B410480OtherBLUE CROSS