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General NPI Number Information
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NPI Number | 1366437410
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Entity Type | Individual
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Provider Name | THOMAS P DYKSTRA MD
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Gender | Male
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 08/07/2013
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Provider Practice Location Address
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Address Line | 2200 RANDALLIA DR
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City | FORT WAYNE
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State | IN
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Zip | 46805-4638
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Country | US
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Telephone | 260-373-4000
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Fax | 260-482-4442
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Provider Business Mailing Address
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Address Line | 3640 NEW VISION DR SUITE A
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City | FORT WAYNE
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State | IN
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Zip | 46845-1717
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Country | US
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Telephone | 260-482-4440
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Fax | 260-482-4442
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 01038525A
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License Number State | IN
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