Provider Demographics
NPI:1700830684
Name:KOOYER, ERIK (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:KOOYER
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 1:3019 COIT AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3376
Mailing Address - Country:US
Mailing Address - Phone:616-365-9575
Mailing Address - Fax:
Practice Address - Street 1:3019 COIT AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3376
Practice Address - Country:US
Practice Address - Phone:616-365-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062075207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4753056Medicaid
MI4898527Medicaid
MI4753065Medicaid
MI4898518Medicaid
MIG59951Medicare UPIN
MIM69390240Medicare ID - Type Unspecified
MIP32930067Medicare ID - Type Unspecified