Provider Demographics
NPI:1568498772
Name:TYKOCKI, CHRISTOPHER DAVID (DO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:TYKOCKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 HOLLY RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2443
Mailing Address - Country:US
Mailing Address - Phone:810-694-2720
Mailing Address - Fax:810-953-4473
Practice Address - Street 1:8245 HOLLY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2443
Practice Address - Country:US
Practice Address - Phone:810-694-2720
Practice Address - Fax:810-953-4473
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICT012113207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4228726Medicaid
MI0980879OtherHEALTH PLUS
MI5404569OtherAETNA
MIOB51658OtherBLUE CROSS BLUE SHIELD
MIG84997Medicare UPIN
ON13500Medicare PIN