Provider Demographics
NPI:1902849029
Name:HENDRICKS, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M261
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-488-2626
Mailing Address - Fax:269-488-2625
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M261
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-488-2626
Practice Address - Fax:269-488-2625
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301033379207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
107985OtherGREAT LAKES HLTH PLAN
MI4999314Medicaid
5276514OtherAETNA PIN
MI1803968251OtherBCBS PIN
MI4238221-10Medicaid
MI4999314Medicaid
MI0C97625076Medicare ID - Type Unspecified
MICG4797Medicare PIN
107985OtherGREAT LAKES HLTH PLAN
MI4999314Medicaid