Basic Information
| Provider Information | |||||||||
| NPI: | 1700871175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIKIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 850 HARVARD WAY | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283000 | ||||||||
| FaxNumber: | 6022306461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | DO2227 | NV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 5101013187 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 5101013187 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | DO2227 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 008768 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | DO2227 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4573808 | 05 | MI | MEDICAID | MD013187 | 01 | BLUE CROSS BLUE SHIELD | OTHER | P00202614 | 01 | MI | RAILROAD MEDICARE | OTHER |