Provider Demographics
NPI:1003816224
Name:HUIZENGA, TAMMY BORN (DO)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:BORN
Last Name:HUIZENGA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:BORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3700 52ND ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9637
Mailing Address - Country:US
Mailing Address - Phone:616-656-3700
Mailing Address - Fax:616-656-3701
Practice Address - Street 1:3700 52ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9637
Practice Address - Country:US
Practice Address - Phone:616-656-3700
Practice Address - Fax:616-656-3701
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITB009726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16227001Medicare ID - Type Unspecified
MIE26816Medicare UPIN