Provider Demographics
NPI:1467453456
Name:PEDTKE, DOROTHY A (DO)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:A
Last Name:PEDTKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 52ND ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9637
Mailing Address - Country:US
Mailing Address - Phone:616-656-3700
Mailing Address - Fax:616-656-3701
Practice Address - Street 1:3700 52ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-9637
Practice Address - Country:US
Practice Address - Phone:616-656-3700
Practice Address - Fax:616-656-3701
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDP014363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH64553Medicare UPIN
MID16227006Medicare ID - Type Unspecified