Provider Demographics
NPI:1336633742
Name:MCKELLAR, DEXTER ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:ROBERT
Last Name:MCKELLAR
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 1:300 LAFAYETTE AVE SE STE 4000
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4692
Mailing Address - Country:US
Mailing Address - Phone:616-685-5922
Mailing Address - Fax:
Practice Address - Street 1:1175 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-6407
Practice Address - Country:US
Practice Address - Phone:616-685-8650
Practice Address - Fax:616-791-2160
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351041142207Q00000X
MI4301115644207Q00000X
MI4301502149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine