Provider Demographics
NPI:1740352277
Name:HOLWERDA, HARRY LEE (M D)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:LEE
Last Name:HOLWERDA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 TRICKLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-942-0978
Mailing Address - Fax:616-224-0707
Practice Address - Street 1:2850 KALAMAZOO AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49560
Practice Address - Country:US
Practice Address - Phone:616-224-0407
Practice Address - Fax:616-224-0707
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A75839Medicare UPIN