Healthcare Provider Details

I. General information

NPI: 1720061690
Provider Name (Legal Business Name): JOHN S. DYKSTRA X DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 N OAK TRFY SUITE 100
KANSAS CITY MO
64155-2256
US

IV. Provider business mailing address

PO BOX 414975
KANSAS CITY MO
64141-4975
US

V. Phone/Fax

Practice location:
  • Phone: 816-455-0661
  • Fax: 816-454-1080
Mailing address:
  • Phone: 816-455-0661
  • Fax: 816-454-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR4721
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0516561
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: