Provider Demographics
NPI:1760503171
Name:BOVENKERK, STEPHEN DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DALE
Last Name:BOVENKERK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3002
Mailing Address - Country:US
Mailing Address - Phone:269-982-3368
Mailing Address - Fax:269-983-3238
Practice Address - Street 1:2151 W SPRING ST STE B120
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3210
Practice Address - Country:US
Practice Address - Phone:770-207-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015878207YX0905X
GA82870207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery