Healthcare Provider Details

I. General information

NPI: 1902957194
Provider Name (Legal Business Name): GARY WAYNE DYKES PT, MDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 OLD WEST BROAD ST
ATHENS GA
30606-2853
US

IV. Provider business mailing address

1765 OLD WEST BROAD ST BLDG 2-200
ATHENS GA
30606-2887
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-1663
  • Fax: 706-546-8792
Mailing address:
  • Phone: 706-549-1663
  • Fax: 706-546-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005234
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: