Provider Demographics
NPI:1720081649
Name:HAROLDS, JAY A (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:HAROLDS
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 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7339
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK125622085R0202X
MI43010973712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100009180AMedicaid
OK242419511Medicare ID - Type Unspecified
OKMDLPL006Medicare ID - Type Unspecified
OK100009180AMedicaid
OK244421005Medicare ID - Type Unspecified
OK2RADIA006Medicare ID - Type Unspecified