MEDICARE: MARTIN VANDENAKKER JR. D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	5101009565	MI

General Provider Information

NPI Number	:	1639281215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN VANDENAKKER JR. D.O.

Provider Business Mailing Address
First Line	:	9936 ELK LAKE TRL
Second Line	:
City	:	WILLIAMSBURG
State	:	MI
Zip	:	49690-8514
Country	:	US
Telephone Number	:	231-883-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	9936 ELK LAKE TRL
Second Line	:
City	:	WILLIAMSBURG
State	:	MI
Zip	:	49690-8514
Country	:	US
Telephone Number	:	231-883-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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