Provider Demographics
NPI:1255365334
Name:DEKKINGA, JACK A (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:DEKKINGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1673 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9519
Mailing Address - Country:US
Mailing Address - Phone:616-243-3376
Mailing Address - Fax:162-433-3776
Practice Address - Street 1:1673 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9519
Practice Address - Country:US
Practice Address - Phone:616-243-3376
Practice Address - Fax:616-243-3377
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039679207N00000X
MI5601039679207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070D16223OtherBCBS MI
DX9137OtherMEDICARE RR GROUP
MI1255365334Medicaid
MI11296OtherMEDICARE PTAN GROUP
MIB44398Medicare UPIN