Provider Demographics
NPI:1912953662
Name:SPOOLSTRA, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SPOOLSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 4200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4650
Practice Address - Country:US
Practice Address - Phone:616-685-6919
Practice Address - Fax:616-685-3063
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301050964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4878990Medicaid
MI4194243Medicaid
MI4203852Medicaid
MI3415869Medicaid
MI4879002Medicaid
MI3483125Medicaid
MI4203852Medicaid
MIP32930147Medicare ID - Type Unspecified
MIM02830116Medicare ID - Type Unspecified
MI3483125Medicaid