Provider Demographics
NPI:1801849120
Name:VANDERKOOI, THEODORE J (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:VANDERKOOI
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
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 1:230 W OAK ST
Practice Address - Street 2:SUITE 201
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1575
Practice Address - Country:US
Practice Address - Phone:231-924-4200
Practice Address - Fax:616-267-9046
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI065627208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4205310Medicaid
MIH16487Medicare UPIN
MIF26007017Medicare ID - Type UnspecifiedMEDICARE NUMBER