Basic Information
| Provider Information | |||||||||
| NPI: | 1710916341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3243 E MURDOCK ST | ||||||||
| Address2: | SUITE #500 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169622080 | ||||||||
| FaxNumber: | 3169622079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3243 E MURDOCK ST | ||||||||
| Address2: | SUITE #500 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169622080 | ||||||||
| FaxNumber: | 3169622079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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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 | 2080P0205X | 28093 | KS | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 12149357 | 01 | KS | MULTIPLAN | OTHER | 055541 | 01 | KS | BCBS | OTHER | 200626 | 01 | KS | HPK | OTHER | 11872 | 01 | KS | PHS | OTHER | 100333960A | 05 | KS | MEDICAID | 16997 | 01 | KS | COVENTRY | OTHER |