Healthcare Provider Details

I. General information

NPI: 1356468102
Provider Name (Legal Business Name): RENO JACKSON DYKES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7969 ASHTON AVE
MANASSAS VA
20109-2885
US

IV. Provider business mailing address

7969 ASHTON AVE
MANASSAS VA
20109-2885
US

V. Phone/Fax

Practice location:
  • Phone: 703-792-7800
  • Fax: 703-792-5699
Mailing address:
  • Phone: 703-792-7800
  • Fax: 703-792-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101022041
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: