Provider Demographics
NPI:1255458592
Name:WEITEKAMP, LEE ANN (MD)
Entity type:Individual
Prefix:
First Name:LEE ANN
Middle Name:
Last Name:WEITEKAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1304
Mailing Address - Country:US
Mailing Address - Phone:616-233-8574
Mailing Address - Fax:
Practice Address - Street 1:1036 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1304
Practice Address - Country:US
Practice Address - Phone:616-233-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064996207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine