Individual
DR. MATTHEW LICERALDE ELLOSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 MICHIGAN ST NE, SUITE A721, GRAND RAPIDS, MI 49503-2560
(616) 391-3139
(616) 391-3044
Mailing address
100 MICHIGAN ST NE, MC 845, GRAND RAPIDS, MI 49503-2560
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
4301096516
MI
Other
Enumeration date
07/22/2010
Last updated
06/28/2021
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