Provider Demographics
NPI:1033199674
Name:DYK, RANDALL L (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:DYK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MALL DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2878
Mailing Address - Country:US
Mailing Address - Phone:269-350-8434
Mailing Address - Fax:
Practice Address - Street 1:670 MALL DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2878
Practice Address - Country:US
Practice Address - Phone:269-491-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076181208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4630842Medicaid
MICA4396OtherRAILROAD MEDICARE
MI4526826Medicaid
MI4526826Medicaid
MIM20520034Medicare PIN