Healthcare Provider Details

I. General information

NPI: 1770595563
Provider Name (Legal Business Name): MARILYN ESTRADA INTENGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

PO BOX 77000 DEPT # 77339
DETROIT MI
48277-0339
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-6700
  • Fax: 616-364-4960
Mailing address:
  • Phone: 616-364-6700
  • Fax: 616-364-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number4301084873
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: