Provider Demographics
NPI:1669405163
Name:FLENTJE, GREGORY L (MD PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:FLENTJE
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 60TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7065
Mailing Address - Country:US
Mailing Address - Phone:616-719-4488
Mailing Address - Fax:616-719-4480
Practice Address - Street 1:1403 60TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7065
Practice Address - Country:US
Practice Address - Phone:616-719-4488
Practice Address - Fax:616-719-4480
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010785682084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI380001205OtherRAILROAD MEDICARE
MI260D110830OtherBLUE CROSS AND BLUE SHIEL
MI380001205OtherRAILROAD MEDICARE
0M42950005Medicare PIN
MI260D110830OtherBLUE CROSS AND BLUE SHIEL