Healthcare Provider Details

I. General information

NPI: 1285736371
Provider Name (Legal Business Name): KIRSTEN M JOHANTGEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7895 CURRIER DR
PORTAGE MI
49002-4314
US

IV. Provider business mailing address

5943 STADIUM DR SUITE 3
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-7080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301054491
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: