Healthcare Provider Details

I. General information

NPI: 1609070499
Provider Name (Legal Business Name): JON ANDREW DYKENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 W WASHINGTON BLVD
CHICAGO IL
60612-2428
US

IV. Provider business mailing address

1034 W BELMONT AVE APT 2REAR
CHICAGO IL
60657-6743
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: