Healthcare Provider Details

I. General information

NPI: 1013940980
Provider Name (Legal Business Name): MARIA E DIMUSTO-POORTENGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIEL ELIZABETH DIMUSTOPOORTENGA MD

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE NICU
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

245 STATE ST SE
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-752-6554
  • Fax:
Mailing address:
  • Phone:
  • Fax: 616-913-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301068818
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35C001071
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number1013940980
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME141884
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301068818
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: