Provider Demographics
NPI:1578523502
Name:DENNIS, JONATHAN ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ANDREW
Last Name:DENNIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:111 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:MI
Practice Address - Zip Code:49688-5113
Practice Address - Country:US
Practice Address - Phone:231-832-8560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114549393Medicaid
MI0856711995OtherBC/BS PIN
H91639Medicare UPIN
MI1734751OtherCIGNA
P00028714Medicare PIN
F76001120Medicare PIN