Healthcare Provider Details

I. General information

NPI: 1811961899
Provider Name (Legal Business Name): DONALD EZRA RUTHERFORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 S HARBOR DR SUITE C4
GRAND HAVEN MI
49417-1796
US

IV. Provider business mailing address

PO BOX 3140
GRAND RAPIDS MI
49501-3140
US

V. Phone/Fax

Practice location:
  • Phone: 616-844-4068
  • Fax: 616-844-4068
Mailing address:
  • Phone: 616-844-4068
  • Fax: 616-844-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009705
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number5101009705
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: