Individual
JACK O DERKS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
601 MICHIGAN AVE STE 104, HOLLAND, MI 49423-4951
(616) 392-2361
(616) 392-2364
Mailing address
601 MICHIGAN AVE STE 104, HOLLAND, MI 49423-4951
(616) 392-2361
(616) 392-2364
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4301028907
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080G047000
BLUE CROSS BLUE SHIELD
—
05
—
101138661
—
MI
Enumeration date
07/13/2006
Last updated
12/11/2007
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