Healthcare Provider Details

I. General information

NPI: 1124123476
Provider Name (Legal Business Name): LOURENS J WILLEKES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 LAFEYETTE NW
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

2218 N THRUSH CT SE
GRAND RAPIDS MI
49546-7525
US

V. Phone/Fax

Practice location:
  • Phone: 616-742-9945
  • Fax: 616-742-9967
Mailing address:
  • Phone: 616-742-9945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301080880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: