Provider Demographics
NPI:1396702312
Name:DECOOK, DANIEL J (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:DECOOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-394-0673
Mailing Address - Fax:616-394-9825
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-394-0673
Practice Address - Fax:616-394-9825
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3394929Medicaid
MI020G010060OtherBLUE CROSS BLUE SHIELD MI
382809956OtherCOMMERCIAL
382809956OtherCOMMERCIAL
MI3394929Medicaid