Provider Demographics
NPI:1366437410
Name:DYKSTRA, THOMAS P (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3640 NEW VISION DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1717
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038525A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082528OtherANTHEM
000000004849OtherMPLAN
IN200033350Medicaid
OH2517940Medicaid
930027063Medicare ID - Type UnspecifiedRR MEDICARE
IN047840DDMedicare ID - Type Unspecified
IN200033350Medicaid