Healthcare Provider Details

I. General information

NPI: 1568498772
Provider Name (Legal Business Name): CHRISTOPHER DAVID TYKOCKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8245 HOLLY RD SUITE 103
GRAND BLANC MI
48439-2443
US

IV. Provider business mailing address

8245 HOLLY RD SUITE 103
GRAND BLANC MI
48439-2443
US

V. Phone/Fax

Practice location:
  • Phone: 810-694-2720
  • Fax: 810-953-4473
Mailing address:
  • Phone: 810-694-2720
  • Fax: 810-953-4473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberCT012113
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: