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NPI Code Detail

MEDICARE: JONATHAN DYKSTRA MD

MEDICARE: JONATHAN DYKSTRA MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianMD00036202WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1255357935
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN DYKSTRA MD
Provider Business Mailing Address
First Line : 1115 SE 164TH AVE DEPT 358
Second Line :
City : VANCOUVER
State : WA
Zip : 98683-8004
Country : US
Telephone Number : 360-735-8100
Fax Number : 360-735-3400
Provider Business Practice Location Address
First Line : 16811 SE MCGILLIVRAY BLVD
Second Line :
City : VANCOUVER
State : WA
Zip : 98683-3404
Country : US
Telephone Number : 360-735-8100
Fax Number : 360-735-3400
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2006
Last Update Date : 02/29/2016

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Directions to “ JONATHAN DYKSTRA MD” Practice Location

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