Healthcare Provider Details

I. General information

NPI: 1558471284
Provider Name (Legal Business Name): RANDALL SCOTT KUNTZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DR SE
GRAND RAPIDS MI
49546-8294
US

IV. Provider business mailing address

4070 LAKE DR SE
GRAND RAPIDS MI
49546-8294
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4340
  • Fax: 616-949-4341
Mailing address:
  • Phone: 616-949-4340
  • Fax: 616-949-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301073862
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: