Healthcare Provider Details

I. General information

NPI: 1639281215
Provider Name (Legal Business Name): MARTIN VANDENAKKER JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9936 ELK LAKE TRL
WILLIAMSBURG MI
49690-8514
US

IV. Provider business mailing address

9936 ELK LAKE TRL
WILLIAMSBURG MI
49690-8514
US

V. Phone/Fax

Practice location:
  • Phone: 231-883-7700
  • Fax:
Mailing address:
  • Phone: 231-883-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101009565
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: