Provider Demographics
NPI:1154809507
Name:VAN DYCK, ALEXANDER (OD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:VAN DYCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5399 WILLISTON RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-5321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5399 WILLISTON RD STE 102
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-5321
Practice Address - Country:US
Practice Address - Phone:802-864-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2649152W00000X
VA0618002803152W00000X
VT030.0133954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist