Provider Demographics
NPI:1114946506
Name:WIADUCK, JAMES PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PATRICK
Last Name:WIADUCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-0334
Mailing Address - Country:US
Mailing Address - Phone:231-798-8337
Mailing Address - Fax:231-798-9816
Practice Address - Street 1:4461 GRAND HAVEN RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5548
Practice Address - Country:US
Practice Address - Phone:231-798-8337
Practice Address - Fax:231-798-9816
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010665792084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID24387Medicare UPIN
MION10230Medicare ID - Type Unspecified