Healthcare Provider Details

I. General information

NPI: 1801849120
Provider Name (Legal Business Name): THEODORE J. VANDERKOOI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 MERCY DR
MUSKEGON MI
49444-1835
US

IV. Provider business mailing address

1316 MERCY DR
MUSKEGON MI
49444-1835
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-9461
  • Fax: 231-739-1984
Mailing address:
  • Phone: 231-739-9461
  • Fax: 231-739-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number065627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: