Provider Demographics
NPI:1063658391
Name:HOLWERDA, ROSS ALAN
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:ALAN
Last Name:HOLWERDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 WINCHESTER ROAD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721
Mailing Address - Country:US
Mailing Address - Phone:229-347-1703
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2107
Practice Address - Fax:816-932-2843
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120164802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology