Provider Demographics
NPI:1124123476
Name:WILLEKES, LOURENS J (MD)
Entity type:Individual
Prefix:
First Name:LOURENS
Middle Name:J
Last Name:WILLEKES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 N THRUSH CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7525
Mailing Address - Country:US
Mailing Address - Phone:616-742-9945
Mailing Address - Fax:
Practice Address - Street 1:751 LAFEYETTE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-742-9945
Practice Address - Fax:616-742-9967
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080880208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4507446Medicaid
MIA00821Medicare UPIN
MI4507446Medicaid