Provider Demographics
NPI:1548245475
Name:LENTERS, DERICK J (MD)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:J
Last Name:LENTERS
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 1:664 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4944
Mailing Address - Country:US
Mailing Address - Phone:616-392-5973
Mailing Address - Fax:616-392-1646
Practice Address - Street 1:664 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4944
Practice Address - Country:US
Practice Address - Phone:616-392-5973
Practice Address - Fax:616-392-1646
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDL025521207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1423146Medicaid
0702408Medicare ID - Type Unspecified
MI1423146Medicaid