Basic Information
| Provider Information | |||||||||
| NPI: | 1043206113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159618448 | ||||||||
| FaxNumber: | 5156439100 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 E SCENIC VALLEY AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501254865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159618448 | ||||||||
| FaxNumber: | 5156439100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 31362 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 31362 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-31362 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043206113 | 01 | IA | NPI | OTHER | 56091003 | 01 | IA | MEDICARE PTAN | OTHER |