Provider Demographics
NPI:1003126830
Name:VAN DYK, GRIETJE (MD)
Entity Type:Individual
Prefix:
First Name:GRIETJE
Middle Name:
Last Name:VAN DYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 KATELLA AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3353
Mailing Address - Country:US
Mailing Address - Phone:562-314-1400
Mailing Address - Fax:562-431-0564
Practice Address - Street 1:3851 KATELLA AVE STE 150
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3353
Practice Address - Country:US
Practice Address - Phone:562-314-1400
Practice Address - Fax:562-431-0564
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61231207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF53209Medicare UPIN