Provider Demographics
NPI:1205807955
Name:SCHROTENBOER, DIRK (OD)
Entity type:Individual
Prefix:DR
First Name:DIRK
Middle Name:
Last Name:SCHROTENBOER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11971 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9610
Mailing Address - Country:US
Mailing Address - Phone:616-395-0606
Mailing Address - Fax:616-395-0070
Practice Address - Street 1:11971 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9610
Practice Address - Country:US
Practice Address - Phone:616-395-0606
Practice Address - Fax:616-395-0070
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI521576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2940256Medicaid
MI900G065210OtherBLUECROSS BLUESHIELD ID
MIT33528Medicare UPIN
MI2940256Medicaid