Provider Demographics
NPI:1588621239
Name:FIX, DONALD MOFFAT (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:MOFFAT
Last Name:FIX
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:PO BOX 1237
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1237
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-975-1870
Practice Address - Street 1:602 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-394-3522
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030846207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
B43666Medicare UPIN
MIG06256004Medicare ID - Type Unspecified