Basic Information
| Provider Information | |||||||||
| NPI: | 1093747404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOTMAN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | STE 1A | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 LAFAYETTE AVE SE | ||||||||
| Address2: | STE 2045 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301031477 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 4301031477 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 4308095 | 05 | MI | MEDICAID | 4880086 | 05 | MI | MEDICAID |