Provider Demographics
NPI:1134144413
Name:DERKS, JACK O (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:O
Last Name:DERKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MICHIGAN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-392-2361
Mailing Address - Fax:616-392-2364
Practice Address - Street 1:601 MICHIGAN AVE STE 104
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-392-2361
Practice Address - Fax:616-392-2364
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080G047000OtherBLUE CROSS BLUE SHIELD
MI101138661Medicaid
MI0G04700003Medicare PIN
080G047000OtherBLUE CROSS BLUE SHIELD