Provider Demographics
NPI:1194163279
Name:VANDEVREDE, KENT W (DO)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:W
Last Name:VANDEVREDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1560 E SHERMAN BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1854
Mailing Address - Country:US
Mailing Address - Phone:231-672-3883
Mailing Address - Fax:231-672-3973
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-672-3883
Practice Address - Fax:231-672-3973
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020679207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine