Basic Information
| Provider Information | |||||||||
| NPI: | 1477060218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYKES MEDICAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 LOBLOLLY LN NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396019217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016959464 | ||||||||
| FaxNumber: | 6018236777 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MILLS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018335608 | ||||||||
| FaxNumber: | 6018236777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2018 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | DYKES | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | GERRIT | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6016959464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MS15940 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00124038 | 05 | MS | MEDICAID |