Provider Demographics
NPI:1457462467
Name:OCONNOR, RICHARD PHILLIP JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PHILLIP
Last Name:OCONNOR
Suffix:JR
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 150185
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-0185
Mailing Address - Country:US
Mailing Address - Phone:616-866-2539
Mailing Address - Fax:616-866-3135
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:STE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-774-8200
Practice Address - Fax:616-774-0304
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRO044045207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3371432Medicaid
MI044045OtherMEDICAL LICENSE
MI044045OtherMEDICAL LICENSE