Provider Demographics
NPI:1508077165
Name:ROBERT DEJONGE DO PC
Entity Type:Organization
Organization Name:ROBERT DEJONGE DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-866-4474
Mailing Address - Street 1:350 NORTHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1401
Mailing Address - Country:US
Mailing Address - Phone:616-866-4474
Mailing Address - Fax:616-866-4476
Practice Address - Street 1:350 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1401
Practice Address - Country:US
Practice Address - Phone:616-866-4474
Practice Address - Fax:616-866-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI111719945Medicaid
MI111719945Medicaid