Provider Demographics
NPI:1811336506
Name:HOLSWORTH, AMANDA RUDERT (DO)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:RUDERT
Last Name:HOLSWORTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CLAIRE
Other - Last Name:RUDERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3271 CLEAR VISTA CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-267-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020432208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics