Healthcare Provider Details

I. General information

NPI: 1932280872
Provider Name (Legal Business Name): SUSAN M DYKEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 MENTOR AVE STE 100
MENTOR OH
44060-4496
US

IV. Provider business mailing address

PO BOX 74568
CLEVELAND OH
44194-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-383-0100
  • Fax: 216-383-6481
Mailing address:
  • Phone: 440-974-4411
  • Fax: 440-974-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35060874
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: