1659365518 NPI number — ELIZABETH P DYKSTRA MD

Table of content: ELIZABETH P DYKSTRA MD (NPI 1659365518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659365518 NPI number — ELIZABETH P DYKSTRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYKSTRA
Provider First Name:
ELIZABETH
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PONDER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659365518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 22ND AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-1852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
629-255-3486
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 WESTGATE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37027-8035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
629-255-2095
Provider Business Practice Location Address Fax Number:
629-255-4107
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  35225 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1502891 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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