Provider Demographics
NPI:1053524884
Name:BLOSTICA, LYNNETTE RAYE (OD)
Entity type:Individual
Prefix:DR
First Name:LYNNETTE
Middle Name:RAYE
Last Name:BLOSTICA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4624
Mailing Address - Country:US
Mailing Address - Phone:269-329-5860
Mailing Address - Fax:269-329-5865
Practice Address - Street 1:3412 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4624
Practice Address - Country:US
Practice Address - Phone:269-329-5860
Practice Address - Fax:269-329-5865
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945215713Medicaid
MIOM601300011Medicare PIN
MI945215713Medicaid