Provider Demographics
NPI:1780660381
Name:WIERENGA, CAROL MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:MARIE
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4328 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1077
Mailing Address - Country:US
Mailing Address - Phone:517-764-3609
Mailing Address - Fax:517-764-3659
Practice Address - Street 1:4328 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1077
Practice Address - Country:US
Practice Address - Phone:517-764-3609
Practice Address - Fax:517-764-3659
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2010-11-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301074081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I00947Medicare UPIN