Healthcare Provider Details

I. General information

NPI: 1235180142
Provider Name (Legal Business Name): ELMER H VANDYKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 04/19/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 BRIANNA BLVD
SEDALIA MO
65301-2285
US

IV. Provider business mailing address

3131 BRIANNA BLVD
SEDALIA MO
65301-2285
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-1381
  • Fax: 660-827-3001
Mailing address:
  • Phone: 660-826-1381
  • Fax: 660-827-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number27057
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number27057
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: