Provider Demographics
NPI:1639259237
Name:DE KORTE, THOMAS BRUCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRUCE
Last Name:DE KORTE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:1404 BRIDGE STREET
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-0103
Mailing Address - Country:US
Mailing Address - Phone:231-547-4662
Mailing Address - Fax:231-547-3068
Practice Address - Street 1:1404 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-2603
Practice Address - Country:US
Practice Address - Phone:231-547-4662
Practice Address - Fax:231-547-3068
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITD001078213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1441583Medicaid
MI5155000OtherBLUE CROSS
MI5155000Medicare PIN
MI1441583Medicaid
MI0801100001Medicare NSC