MEDICARE: DR. ALEXANDER VAN DYCK OD

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	152W00000X	Optometrist	TA2649	MD
2	152W00000X	Optometrist	0618002803	VA
3	152W00000X	Optometrist	030.0133954	VT

General Provider Information

NPI Number	:	1154809507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER VAN DYCK OD

Provider Business Mailing Address
First Line	:	5399 WILLISTON RD STE 102
Second Line	:
City	:	WILLISTON
State	:	VT
Zip	:	05495-5321
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5399 WILLISTON RD STE 102
Second Line	:
City	:	WILLISTON
State	:	VT
Zip	:	05495-5321
Country	:	US
Telephone Number	:	802-864-5428
Fax Number	:

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

Provider Enumeration Date	:	07/29/2018
Last Update Date	:	08/12/2022

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