Healthcare Provider Details

I. General information

NPI: 1780810697
Provider Name (Legal Business Name): ROBERT MAX DYKSTERHOUSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 W CLARK RD STE 100
YPSILANTI MI
48197-0860
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR # J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-1188
  • Fax: 734-971-3658
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301510567
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number253101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: