Provider Demographics
NPI:1689632911
Name:ABEN, GERALD RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RICHARD
Last Name:ABEN
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 1:804 SERVICE ROAD
Mailing Address - Street 2:ROOM A204
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7037
Mailing Address - Country:US
Mailing Address - Phone:517-353-4920
Mailing Address - Fax:
Practice Address - Street 1:804 SERVICE ROAD
Practice Address - Street 2:ROOM A204
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7037
Practice Address - Country:US
Practice Address - Phone:517-353-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010424532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1689632911Medicaid
MI2900312Medicaid
MI2900312Medicaid
MI1689632911Medicaid