Healthcare Provider Details

I. General information

NPI: 1952321952
Provider Name (Legal Business Name): DOUGLAS J WUNDERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/27/2023
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST STE 100
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

601 JOHN ST BOX 42
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-373-1592
  • Fax: 269-373-6270
Mailing address:
  • Phone: 269-373-1592
  • Fax: 269-373-6270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301405380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: