Provider Demographics
NPI:1255385142
Name:KRIEGER, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KRIEGER
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 1:245 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:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:2080 44TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5010
Practice Address - Country:US
Practice Address - Phone:616-685-8100
Practice Address - Fax:616-455-5052
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3403895Medicaid
MI4179031Medicaid
MI4878319Medicaid
MI3415706Medicaid
MI4155610Medicaid
MIP32930100Medicare ID - Type Unspecified
MI3415706Medicaid
MIM02830085Medicare ID - Type Unspecified
MI4155610Medicaid
MI3403895Medicaid