Provider Demographics
NPI:1922155332
Name:WALEN, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WALEN
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 1:1211 LAFAYETTE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5092
Mailing Address - Country:US
Mailing Address - Phone:616-336-8800
Mailing Address - Fax:616-336-9700
Practice Address - Street 1:1211 LAFAYETTE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5092
Practice Address - Country:US
Practice Address - Phone:616-336-8800
Practice Address - Fax:616-336-9700
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4502600Medicaid
MI23330Medicaid
MI4502600Medicaid