Provider Demographics
NPI:1861497562
Name:WALVOORD, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:WALVOORD
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 1:577 MICHIGAN AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-692-1816
Mailing Address - Fax:616-392-1292
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:STE 201
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-692-1816
Practice Address - Fax:616-392-1292
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301033442208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44920Medicare UPIN
MIOGO6075001Medicare ID - Type Unspecified