Provider Demographics
NPI:1215143797
Name:DEHORN, KATHLEEN URBAN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:URBAN
Last Name:DEHORN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5030 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3725
Mailing Address - Country:US
Mailing Address - Phone:616-954-2020
Mailing Address - Fax:616-949-0408
Practice Address - Street 1:5030 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3725
Practice Address - Country:US
Practice Address - Phone:616-954-2020
Practice Address - Fax:616-949-0408
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258069207W00000X
MI4301083642207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2022325Medicare PIN