Healthcare Provider Details

I. General information

NPI: 1841328614
Provider Name (Legal Business Name): GREGORY S VAN DYKE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 VENTURA CT STE C
STUDIO CITY CA
91604-2471
US

IV. Provider business mailing address

12409 VENTURA CT STE C
STUDIO CITY CA
91604-2471
US

V. Phone/Fax

Practice location:
  • Phone: 818-900-6007
  • Fax: 818-900-6607
Mailing address:
  • Phone: 818-900-6007
  • Fax: 818-900-6607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberA81049
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA81049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: