Provider Demographics
NPI:1215985114
Name:MULDER, JOHN ADRIAN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ADRIAN
Last Name:MULDER
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 1:16310 RIVERDALE CT
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1460
Mailing Address - Country:US
Mailing Address - Phone:616-293-3615
Mailing Address - Fax:616-825-6079
Practice Address - Street 1:16310 RIVERDALE CT
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456
Practice Address - Country:US
Practice Address - Phone:616-293-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34321174400000X
MI4301043859207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3863027Medicaid
TNB47763Medicare UPIN
TN3863027Medicaid