Basic Information
Provider Information | |||||||||
NPI: | 1740253277 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DYKSTRA | ||||||||
FirstName: | ARTHUR | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DYKSTRA | ||||||||
OtherFirstName: | A. | ||||||||
OtherMiddleName: | MICHAEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 E OUTER RD S | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | MO | ||||||||
PostalCode: | 634351702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172226550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1025 MAINE ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 623014038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172226550 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2006 | ||||||||
LastUpdateDate: | 03/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R4356 | MO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 240189902 | 05 | MO |   | MEDICAID |