Provider Demographics
NPI:1851389332
Name:DEMAAGD, ROBERT L (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:DEMAAGD
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 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-464-6170
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-464-6170
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052575207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4761568Medicaid
P00Z40360OtherRR MEDICARE
P00Z40360OtherRR MEDICARE
A77845Medicare UPIN
0D14869Medicare ID - Type Unspecified