Healthcare Provider Details

I. General information

NPI: 1285980193
Provider Name (Legal Business Name): JOHANNA ASTRID ZEA-HERNANDEZ M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2012
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE SUITE 3003
GRAND RAPIDS MI
49503-2514
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2200
  • Fax: 616-267-2201
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number4301108747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: