Healthcare Provider Details

I. General information

NPI: 1033199674
Provider Name (Legal Business Name): RANDALL L DYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 MALL DR
PORTAGE MI
49024-2878
US

IV. Provider business mailing address

670 MALL DR
PORTAGE MI
49024-2878
US

V. Phone/Fax

Practice location:
  • Phone: 269-491-3263
  • Fax:
Mailing address:
  • Phone: 269-350-8434
  • Fax: 269-350-8434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301076181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: