Provider Demographics
NPI:1720061690
Name:DYKSTRA, JOHN S X (DO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:DYKSTRA
Suffix:X
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:PO BOX 414975
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-4975
Mailing Address - Country:US
Mailing Address - Phone:816-455-0661
Mailing Address - Fax:816-454-1080
Practice Address - Street 1:9501 N OAK TRFY
Practice Address - Street 2:SUITE 100
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2256
Practice Address - Country:US
Practice Address - Phone:816-455-0661
Practice Address - Fax:816-454-1080
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR47212085R0202X
KS05165612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240394122Medicaid
MO2239077OtherAETNA
MO03870079OtherBCBS
KS067407OtherBCBS
KS100231260AMedicaid
KS3373146OMedicare ID - Type Unspecified
KS067407OtherBCBS
MO3373146Medicare ID - Type Unspecified
MO03870079OtherBCBS