Provider Demographics
NPI:1164434346
Name:CLODFELDER, RICHARD P (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
Last Name:CLODFELDER
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 1:2000 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3023
Mailing Address - Country:US
Mailing Address - Phone:616-776-2400
Mailing Address - Fax:
Practice Address - Street 1:75 SHELDON BLVD SE
Practice Address - Street 2:STE 106
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4224
Practice Address - Country:US
Practice Address - Phone:616-776-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301026348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3211420Medicaid