Provider Demographics
NPI:1689664872
Name:WIERENGA, ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:
Last Name:WIERENGA
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 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:517-780-9286
Practice Address - Street 1:505 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1266
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:517-780-9286
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAW028076174400000X
MI4301028076207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1689664872Medicaid
MI3913940002Medicare NSC
MIA73305Medicare UPIN
MI0C84729001Medicare ID - Type Unspecified
MI3913940001Medicare NSC