Provider Demographics
NPI:1508120122
Name:ROUWHORST, JONATHAN STEWART (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:STEWART
Last Name:ROUWHORST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15161 WILLOWWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15161 WILLOWWOOD CT
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-402-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062119207Q00000X
WI64639207Q00000X
MI4301110884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400251829Medicare PIN
WIP01667993Medicare PIN