Provider Demographics
NPI:1619958576
Name:VYDARENY, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:VYDARENY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:833 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3523
Mailing Address - Country:US
Mailing Address - Phone:616-459-1144
Mailing Address - Fax:616-459-0313
Practice Address - Street 1:833 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3523
Practice Address - Country:US
Practice Address - Phone:616-459-1144
Practice Address - Fax:616-459-0313
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJV028722207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1075285Medicaid
MIP09760006Medicare PIN
MI1075285Medicaid