Healthcare Provider Details

I. General information

NPI: 1154689420
Provider Name (Legal Business Name): IGOR DYKAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PKWY
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3492
  • Fax: 765-983-7958
Mailing address:
  • Phone: 765-983-3293
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61568690
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01086406A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: