Provider Demographics
NPI:1811961899
Name:RUTHERFORD, DONALD EZRA (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:EZRA
Last Name:RUTHERFORD
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:PO BOX 3140
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3140
Mailing Address - Country:US
Mailing Address - Phone:616-844-4068
Mailing Address - Fax:616-844-4068
Practice Address - Street 1:1159 S HARBOR DR
Practice Address - Street 2:SUITE C4
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1796
Practice Address - Country:US
Practice Address - Phone:616-844-4068
Practice Address - Fax:616-844-4068
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009705207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080184167Medicare PIN
N97720001Medicare PIN
E37610Medicare UPIN