Provider Demographics
NPI:1417980822
Name:OETMAN, DUANE (MD)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:OETMAN
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7751 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8001
Practice Address - Country:US
Practice Address - Phone:616-878-3321
Practice Address - Fax:616-878-0858
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDO076591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP106668OtherBCN
MI080D16151OtherBXBS
MI4221378Medicaid
MI4221378Medicaid
MI0D16150224Medicare PIN
MIP106668OtherBCN