Healthcare Provider Details

I. General information

NPI: 1609004308
Provider Name (Legal Business Name): MATTHEW J DYKHUIZEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 CHANCELLOR DR SUITE 215
CRESTVIEW HILLS KY
41017-3912
US

IV. Provider business mailing address

2865 CHANCELLOR DR STE 215
CRESTVIEW HILLS KY
41017-3931
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-2079
  • Fax: 859-581-7207
Mailing address:
  • Phone: 859-344-2079
  • Fax: 859-581-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35.128411
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number46137
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number35.128411
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number46137
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: