Healthcare Provider Details

I. General information

NPI: 1053303479
Provider Name (Legal Business Name): DAVID M DYCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 COUNTY ROAD 6 E
ELKHART IN
46514-7673
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-264-9635
  • Fax: 574-262-0398
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01067738A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: