Basic Information
| Provider Information | |||||||||
| NPI: | 1295873529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID VAN DYKE MD SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 187 | ||||||||
| Address2: | 122 W SOUTH ST | ||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546650187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086372511 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546650187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086372511 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOTH | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6086372511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 19557020 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 30101600 | 05 | WI | MEDICAID |