Provider Demographics
NPI:1720283633
Name:GENDERNALIK, JAMES DRISCOLL (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DRISCOLL
Last Name:GENDERNALIK
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 1:2500 NILES RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3225
Mailing Address - Country:US
Mailing Address - Phone:269-429-5000
Mailing Address - Fax:
Practice Address - Street 1:2500 NILES RD STE 1
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3225
Practice Address - Country:US
Practice Address - Phone:269-429-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101017990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program