Healthcare Provider Details

I. General information

NPI: 1356423636
Provider Name (Legal Business Name): RICHARD W. VISSER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 OTTAWA AVE NW
GRAND RAPIDS MI
49503-1431
US

IV. Provider business mailing address

973 OTTAWA AVE NW
GRAND RAPIDS MI
49503-1431
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-7752
  • Fax: 616-391-7733
Mailing address:
  • Phone: 616-391-7752
  • Fax: 616-391-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number4301040706
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: