Provider Demographics
NPI:1275748121
Name:SOUBLIERE, COURTNEY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:ANN
Last Name:SOUBLIERE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:CASTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:300 LAFAYETTE SE
Practice Address - Street 2:STE 2045
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-3098
Practice Address - Fax:616-685-3095
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015706207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP32930443Medicare PIN