Provider Demographics
NPI:1790764868
Name:TACKET, DOUGLAS GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GREGORY
Last Name:TACKET
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 1:4077 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4077 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9513
Practice Address - Country:US
Practice Address - Phone:269-429-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001246A207Q00000X
MI5101012140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114560327Medicaid
0851101104OtherBCBS
IN236040362OtherMEDICARE PTAN
IN300049695Medicaid
236040362OtherMEDICARE PTAN