Provider Demographics
NPI:1700825296
Name:KNIBBE, JEFFRY D (MD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:D
Last Name:KNIBBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6105 WILSON AVE SW
Practice Address - Street 2:SUITE 202
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-9714
Practice Address - Country:US
Practice Address - Phone:616-486-5229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70604Medicare UPIN
MIM74460188Medicare PIN