Provider Demographics
NPI:1285680082
Name:ROMERO, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ROMERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:730 GRANDVILLE AVE SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4920
Practice Address - Country:US
Practice Address - Phone:616-685-8400
Practice Address - Fax:616-742-1322
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4809563Medicaid
MI4878140Medicaid
MI4891722Medicaid
MIM02830152Medicare ID - Type Unspecified
MIM69390247Medicare ID - Type Unspecified
MI4809563Medicaid