Provider Demographics
NPI:1053405548
Name:KROEZE, JON W (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:W
Last Name:KROEZE
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 1:382 N 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-396-6516
Mailing Address - Fax:616-396-2513
Practice Address - Street 1:382 N 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-396-6516
Practice Address - Fax:616-396-2513
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIO80083063OtherRAILROAD MEDICARE
MI0410183OtherBCBS
MI3046460Medicaid
MIF70275Medicare UPIN
MI3046460Medicaid