Provider Demographics
NPI:1215120035
Name:DONALDDVANDYKENMDLTD
Entity type:Organization
Organization Name:DONALDDVANDYKENMDLTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDYKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-786-3555
Mailing Address - Street 1:900 RYLAND ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1605
Mailing Address - Country:US
Mailing Address - Phone:775-786-3555
Mailing Address - Fax:775-786-3088
Practice Address - Street 1:900 RYLAND ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1605
Practice Address - Country:US
Practice Address - Phone:775-786-3555
Practice Address - Fax:775-786-3088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWJBBVMedicare PIN