Provider Demographics
NPI:1437220241
Name:LOUDER, MARY LOUISE (DO)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
Last Name:LOUDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3700 52ND ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9637
Mailing Address - Country:US
Mailing Address - Phone:616-656-3700
Mailing Address - Fax:616-656-3701
Practice Address - Street 1:2695 PINEHILL DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-201-8955
Practice Address - Fax:616-656-3701
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL-1033207Q00000X
COCO 40167207Q00000X
OH34-008880207Q00000X
MIMI5101012165207Q00000X
IN02003339A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF98047Medicare UPIN
MIF98047Medicare UPIN