Provider Demographics
NPI:1639281215
Name:VANDENAKKER, MARTIN JR (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:VANDENAKKER
Suffix:JR
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 1:9936 ELK LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-8514
Mailing Address - Country:US
Mailing Address - Phone:231-883-7700
Mailing Address - Fax:
Practice Address - Street 1:9936 ELK LAKE TRL
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MI
Practice Address - Zip Code:49690-8514
Practice Address - Country:US
Practice Address - Phone:231-883-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010095652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE33179Medicare UPIN