Provider Demographics
NPI:1275274037
Name:GLOUDEMANS, DAVID NEIL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NEIL
Last Name:GLOUDEMANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2662
Mailing Address - Country:US
Mailing Address - Phone:231-201-5693
Mailing Address - Fax:
Practice Address - Street 1:747 E EIGHTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2662
Practice Address - Country:US
Practice Address - Phone:231-201-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist