Provider Demographics
NPI:1053349993
Name:VANWINGEN, JEFFREY JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:VANWINGEN
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 1:721 3 MILE RD NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8229
Mailing Address - Country:US
Mailing Address - Phone:616-647-3770
Mailing Address - Fax:616-647-3776
Practice Address - Street 1:721 3 MILE RD NW
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8229
Practice Address - Country:US
Practice Address - Phone:616-647-3770
Practice Address - Fax:616-647-3776
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJV070262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0804109762OtherBC/BS
MI4194806Medicaid
MI7976213OtherAETNA
MIPH14829OtherPRIORITY HEALTH
MIP106669OtherBLUE CARE NETWORK
MI7976213OtherAETNA
MI0D17659004Medicare UPIN