Provider Demographics
NPI:1487151536
Name:VAN DYKE, JOHN CHANDLER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHANDLER
Last Name:VAN DYKE
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 1:1542 TULANE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2865
Mailing Address - Country:US
Mailing Address - Phone:504-962-6110
Mailing Address - Fax:
Practice Address - Street 1:1118 GULF BREEZE PKWY STE 202
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7803
Practice Address - Country:US
Practice Address - Phone:504-326-8518
Practice Address - Fax:504-386-8218
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.468052085R0202X
LA327710208D00000X
FLME1630762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice