Provider Demographics
NPI:1164416061
Name:HARKINS, MICHAEL DAVID (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:HARKINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5123
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-5123
Mailing Address - Country:US
Mailing Address - Phone:920-336-3353
Mailing Address - Fax:920-336-3108
Practice Address - Street 1:15600 35TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1396
Practice Address - Country:US
Practice Address - Phone:763-710-9905
Practice Address - Fax:763-292-5947
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1844111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000075675Medicare ID - Type Unspecified
T62129Medicare UPIN