Provider Demographics
NPI:1821094129
Name:VANDERKOLK, WAYNE E (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:E
Last Name:VANDERKOLK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1045 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9542
Mailing Address - Country:US
Mailing Address - Phone:616-456-5311
Mailing Address - Fax:616-456-7955
Practice Address - Street 1:1045 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9542
Practice Address - Country:US
Practice Address - Phone:616-456-5311
Practice Address - Fax:616-456-7955
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI057820208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3360653Medicaid
MID16117011Medicare PIN
MIG53702Medicare UPIN