Healthcare Provider Details

I. General information

NPI: 1245226083
Provider Name (Legal Business Name): CORNELIUS MCKOWN DYKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR SUITE 200
GASTONIA NC
28054-2134
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7670
  • Fax: 704-671-7672
Mailing address:
  • Phone: 701-234-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number9800242
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number11686
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: