Healthcare Provider Details

I. General information

NPI: 1558725051
Provider Name (Legal Business Name): JOHN RUSSEL DYKEMA III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6363 FOREST PARK RD,7TH FLOOR STE749
DALLAS TX
75390-2500
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-8500
  • Fax: 214-645-2632
Mailing address:
  • Phone: 214-645-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberS6606
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: