Provider Demographics
NPI:1942248877
Name:DEKRYGER, LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
Last Name:DEKRYGER
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 1:4085 BURTON ST SE
Mailing Address - Street 2:S-200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2444
Mailing Address - Country:US
Mailing Address - Phone:616-284-8888
Mailing Address - Fax:616-284-8848
Practice Address - Street 1:4085 BURTON ST SE
Practice Address - Street 2:S-102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6116
Practice Address - Country:US
Practice Address - Phone:616-284-8888
Practice Address - Fax:616-284-8848
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028165208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16150044Medicare ID - Type Unspecified
B43381Medicare UPIN