Provider Demographics
NPI:1013940980
Name:DIMUSTO-POORTENGA, MARIA E (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:E
Last Name:DIMUSTO-POORTENGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIEL
Other - Middle Name:ELIZABETH
Other - Last Name:DIMUSTOPOORTENGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-913-1818
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:NICU
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-752-6554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068818208000000X, 2080N0001X
OH35C0010712080N0001X
MI10139409802080N0001X
FLME1418842080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0031359Medicaid
MI4120849Medicaid
MI4877886Medicaid