Provider Demographics
NPI:1275559775
Name:MEULENDYK, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MEULENDYK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:MEULENDYK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1983 KEMP RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0142
Mailing Address - Country:US
Mailing Address - Phone:248-335-3134
Mailing Address - Fax:
Practice Address - Street 1:1983 KEMP RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-335-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010078212083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5101007821OtherCONTROLLED SUBSTANCE
MI4802974Medicaid
AM6321638OtherDEA
MI4802974Medicaid
F00587Medicare UPIN
OP17480001Medicare ID - Type Unspecified