Provider Demographics
NPI:1396743084
Name:VANDER VELDE, DAVID DIRK (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:DIRK
Last Name:VANDER VELDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 FRONT AVE NW
Mailing Address - Street 2:SUITE 365
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5325
Mailing Address - Country:US
Mailing Address - Phone:616-920-1816
Mailing Address - Fax:
Practice Address - Street 1:678 FRONT AVE NW
Practice Address - Street 2:SUITE 365
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5325
Practice Address - Country:US
Practice Address - Phone:616-920-1816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010090002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA73598Medicare UPIN
MIM74000/001Medicare ID - Type Unspecified
MI0M74460 614Medicare PIN