Provider Demographics
NPI:1336105014
Name:BEKKER, JEROME (DO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:BEKKER
Suffix:
Gender:M
Credentials:DO
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 700890
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-0955
Mailing Address - Country:US
Mailing Address - Phone:734-453-5360
Mailing Address - Fax:734-453-5380
Practice Address - Street 1:44633 JOY RD STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1731
Practice Address - Country:US
Practice Address - Phone:734-453-5360
Practice Address - Fax:734-453-5380
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB010278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI364570412OtherTAX ID
MI114731255Medicaid
MI364570412OtherTAX ID
MI0P14720Medicare ID - Type Unspecified