Provider Demographics
NPI:1629034178
Name:PIEBENGA, KEVIN JON (DPM, PC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JON
Last Name:PIEBENGA
Suffix:
Gender:M
Credentials:DPM, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1441
Mailing Address - Country:US
Mailing Address - Phone:616-669-7525
Mailing Address - Fax:616-669-9952
Practice Address - Street 1:3330 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1441
Practice Address - Country:US
Practice Address - Phone:616-669-7525
Practice Address - Fax:616-669-9952
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001527213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2693413Medicaid
MI5705467Medicare PIN
MIT96808Medicare UPIN
MI0423670001Medicare NSC