Provider Demographics
NPI:1629046503
Name:VANDERSTELT, ANITA MARIA (DO)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:MARIA
Last Name:VANDERSTELT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:MARIA
Other - Last Name:RAMBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:ATTN: MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7686 GEORGETOWN CTR DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8101
Practice Address - Country:US
Practice Address - Phone:616-252-8600
Practice Address - Fax:616-252-8660
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014733208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M53750099Medicare PIN
MI1629046503Medicaid