Provider Demographics
NPI:1720071657
Name:KIEL, JEFFREY JAY (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAY
Last Name:KIEL
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 1:2030 S STRAITS HWY
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-9792
Mailing Address - Country:US
Mailing Address - Phone:231-649-0935
Mailing Address - Fax:
Practice Address - Street 1:2030 S STRAITS HWY
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9792
Practice Address - Country:US
Practice Address - Phone:231-649-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK010369207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11-4435122Medicaid
ON57390Medicare ID - Type Unspecified
MI11-4435122Medicaid