Basic Information
| Provider Information | |||||||||
| NPI: | 1609004308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKHUIZEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | STE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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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 | 207W00000X | 35.128411 | OH | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 46137 | KY | N | 207WX0107X | 35.128411 | OH | N | 207W00000X | 46137 | KY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0110825 | 05 | OH | MEDICAID | 7100243970 | 05 | KY | MEDICAID |