Provider Demographics
NPI:1427027861
Name:WYNALDA, JAMES M (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:WYNALDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8485 ALGOMA AVE
Mailing Address - Street 2:P.O.BOX 346
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341
Mailing Address - Country:US
Mailing Address - Phone:616-863-6220
Mailing Address - Fax:616-863-6221
Practice Address - Street 1:840 BROOKVILLE PLAZA SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301053498208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11292441OtherCAQH
MI4737974Medicaid
MIF48212Medicare UPIN