Provider Demographics
NPI:1881617439
Name:MULDER, HENRY J (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:J
Last Name:MULDER
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 1:1403 60TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7065
Mailing Address - Country:US
Mailing Address - Phone:616-719-4488
Mailing Address - Fax:616-719-4480
Practice Address - Street 1:1403 60TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7065
Practice Address - Country:US
Practice Address - Phone:616-719-4488
Practice Address - Fax:616-719-4480
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010435202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260042506OtherRAILROAD MEDICARE
MI260D110830OtherBLUE CROSS BLUE SHIELD
MI4277490Medicaid
0M42950001Medicare PIN
MI260042506OtherRAILROAD MEDICARE
MIB43689Medicare UPIN