Provider Demographics
NPI:1225003825
Name:WIEBENGA, PETER J (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:WIEBENGA
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 1:175 S WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7907
Mailing Address - Country:US
Mailing Address - Phone:616-392-5222
Mailing Address - Fax:616-392-3635
Practice Address - Street 1:175 S WAVERLY RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7907
Practice Address - Country:US
Practice Address - Phone:616-392-5222
Practice Address - Fax:616-392-3635
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032024208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32249OtherPJW BCN
MI4301032024OtherPJW STATE
MIPW032024OtherPJW BCBSMI
MI4301032024OtherPJW STATE