Healthcare Provider Details

I. General information

NPI: 1699754457
Provider Name (Legal Business Name): DAVID B VANHOLLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 MAIN STEET
NORWAY MI
49870
US

IV. Provider business mailing address

640 MAIN ST
NORWAY MI
49870-1246
US

V. Phone/Fax

Practice location:
  • Phone: 906-779-7001
  • Fax: 906-779-7006
Mailing address:
  • Phone: 906-779-7001
  • Fax: 906-779-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301074540
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: