Healthcare Provider Details

I. General information

NPI: 1457379240
Provider Name (Legal Business Name): MARK ROBERT WINKLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8622
US

IV. Provider business mailing address

655 KENMOOR AVE SE SUITE A
GRAND RAPIDS MI
49546-8622
US

V. Phone/Fax

Practice location:
  • Phone: 616-575-1212
  • Fax: 616-575-1219
Mailing address:
  • Phone: 616-575-1212
  • Fax: 616-575-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMW075576
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: