Provider Demographics
NPI:1902944895
Name:VANDYKE, DAVID ALAN (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:VANDYKE
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:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:RI
Mailing Address - Zip Code:02826-0760
Mailing Address - Country:US
Mailing Address - Phone:401-568-8555
Mailing Address - Fax:
Practice Address - Street 1:1991 VICTORY HWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:RI
Practice Address - Zip Code:02826-0760
Practice Address - Country:US
Practice Address - Phone:401-568-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0903046Medicaid
RI089003046Medicare PIN
RI0903046Medicaid