Provider Demographics
NPI:1790819449
Name:WIELHOUWER, ERIC JAMES (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:WIELHOUWER
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-0130
Practice Address - Street 1:3185 MACATAWA DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3163
Practice Address - Country:US
Practice Address - Phone:616-391-4500
Practice Address - Fax:616-486-0130
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015494207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114985130Medicaid
MI114985130Medicaid
MIN10270011Medicare PIN