Healthcare Provider Details

I. General information

NPI: 1962693416
Provider Name (Legal Business Name): HENRY OTTENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 WISCONSIN AVE
GRAND HAVEN MI
49417-2472
US

IV. Provider business mailing address

1310 WISCONSIN AVE
GRAND HAVEN MI
49417-2472
US

V. Phone/Fax

Practice location:
  • Phone: 616-846-5080
  • Fax: 616-846-9271
Mailing address:
  • Phone: 616-846-5080
  • Fax: 616-846-9271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number4301028652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: