Provider Demographics
NPI:1609896034
Name:JACK A DEKKINGA MD PC
Entity Type:Organization
Organization Name:JACK A DEKKINGA MD PC
Other - Org Name:WEST MICHIGAN DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:CHARLENE
Authorized Official - Last Name:ANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-257-3344
Mailing Address - Street 1:3434 RIVERTOWN POINT CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3076
Mailing Address - Country:US
Mailing Address - Phone:616-257-3344
Mailing Address - Fax:616-257-1491
Practice Address - Street 1:3434 RIVERTOWN POINT CT SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3076
Practice Address - Country:US
Practice Address - Phone:616-257-3344
Practice Address - Fax:616-257-1491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039679174400000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCI2832OtherMEDICARE RAILROAD GROUP
MI070D16223OtherBCBS OF MICHIGAN
MI0N86210OtherMEDICARE GROUP NUMBER
MI0N86210OtherMEDICARE GROUP NUMBER