Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 4301043859 | MI |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 4301043859 | MI |
NPI | 1215985114 |
---|---|
Provider Name | John Adrian Mulder |
First Address | Grand Rapids, MI 49504 |
Second Address | Grand Rapids, MI 49546-7759 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 29/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3863027 | (05) | TN |
B47763 | (02) | TN |