Provider Demographics
NPI:1114140662
Name:DR. GORDON VANOTTEREN
Entity Type:Organization
Organization Name:DR. GORDON VANOTTEREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:VANOTTEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-968-6866
Mailing Address - Street 1:PO BOX 2994
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-2994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 EAGLE CREST PARK DR
Practice Address - Street 2:STE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty