Healthcare Provider Details

I. General information

NPI: 1689615536
Provider Name (Legal Business Name): MANDIE LEE DYKSTRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E GRIFFIN PKWY
MISSION TX
78572-3106
US

IV. Provider business mailing address

1940 VENTURI DR
HARLINGEN TX
78552-8931
US

V. Phone/Fax

Practice location:
  • Phone: 956-584-3353
  • Fax: 956-584-3253
Mailing address:
  • Phone: 956-873-3769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM2311
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: