Healthcare Provider Details

I. General information

NPI: 1972599009
Provider Name (Legal Business Name): PAUL E VANDYKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1824 MURDOCH AVE
PARKERSBURG WV
26101-3230
US

IV. Provider business mailing address

PO BOX 1385
PARKERSBURG WV
26102-1385
US

V. Phone/Fax

Practice location:
  • Phone: 304-422-6576
  • Fax: 304-485-4466
Mailing address:
  • Phone: 304-422-6576
  • Fax: 304-485-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number10858
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number10858
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: