MEDICARE: DAVID DIRK VANDER VELDE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	5101009000	MI

General Provider Information

NPI Number	:	1396743084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID DIRK VANDER VELDE DO

Provider Business Mailing Address
First Line	:	678 FRONT AVE NW
Second Line	:	SUITE 365
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-920-1816
Fax Number	:

Provider Business Practice Location Address
First Line	:	678 FRONT AVE NW
Second Line	:	SUITE 365
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-920-1816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	05/18/2015

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