Healthcare Provider Details

I. General information

NPI: 1487278545
Provider Name (Legal Business Name): MICHAEL DYKSTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-647-5299
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberETLL-958
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4301514068
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: