Provider Demographics
NPI:1609857143
Name:DEJONG, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DEJONG
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 1:1045 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9542
Mailing Address - Country:US
Mailing Address - Phone:616-456-5311
Mailing Address - Fax:616-456-7955
Practice Address - Street 1:1045 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509
Practice Address - Country:US
Practice Address - Phone:616-456-5311
Practice Address - Fax:616-456-7955
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059493208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16117OtherBCBS
MI3481167Medicaid
MI3481167Medicaid
MI0D16117005Medicare PIN