Provider Demographics
NPI:1407906613
Name:VAN DYKE, MARK WILLIAM (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 11TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1746
Mailing Address - Country:US
Mailing Address - Phone:814-240-6216
Mailing Address - Fax:814-240-6219
Practice Address - Street 1:306 W 11TH ST 2ND FL
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1705
Practice Address - Country:US
Practice Address - Phone:814-240-6216
Practice Address - Fax:814-240-6219
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006067E207PE0004X, 2083X0100X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011147300006Medicaid
B37059Medicare UPIN
PAB 37059Medicare UPIN
PA0011147300006Medicaid