Healthcare Provider Details

I. General information

NPI: 1811578750
Provider Name (Legal Business Name): JARED WILLIAM DOEZEMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 06/07/2024
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 ALGER ST SE
GRAND RAPIDS MI
49507-3530
US

IV. Provider business mailing address

733 ALGER ST SE
GRAND RAPIDS MI
49507-3530
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-9515
  • Fax:
Mailing address:
  • Phone: 616-243-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351048540
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: