Provider Demographics
NPI:1376548107
Name:DEHAAN, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:DEHAAN
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9600
Mailing Address - Fax:605-328-9620
Practice Address - Street 1:27810 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5916
Practice Address - Country:US
Practice Address - Phone:248-516-1978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1919207Q00000X
MI4301511075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5607207Medicaid
SDE25402Medicare UPIN
SD5607207Medicaid
SD080193506Medicare PIN
SD080193525Medicare PIN