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General NPI Number Information
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NPI Number | 1154809507
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Entity Type | Individual
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Provider Name | ALEXANDER VAN DYCK OD
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Gender | Male
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Dates
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Enumeration Date | 07/29/2018
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Last Update Date | 08/12/2022
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Provider Practice Location Address
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Address Line | 5399 WILLISTON RD STE 102
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City | WILLISTON
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State | VT
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Zip | 05495-5321
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Country | US
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Telephone | 802-864-5428
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Fax |
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Provider Business Mailing Address
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Address Line | 5399 WILLISTON RD STE 102
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City | WILLISTON
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State | VT
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Zip | 05495-5321
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TA2649
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618002803
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 030.0133954
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License Number State | VT
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