Individual
DR. DOUGLAS GREGORY TACKET
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
4077 S CLEVELAND AVE, SAINT JOSEPH, MI 49085-9513
(269) 429-2992
Mailing address
4077 S CLEVELAND AVE, SAINT JOSEPH, MI 49085-9513
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
02001246A
IN
207Q00000X
Family Medicine Physician
Primary
5101012140
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0851101104
BCBS
—
05
—
114560327
—
MI
01
—
236040362
MEDICARE PTAN
IN
01
—
236040362
MEDICARE PTAN
—
05
—
300049695
—
IN
Enumeration date
01/17/2006
Last updated
02/22/2024
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