Provider Demographics
NPI:1033172192
Name:DYKSTRA, GARY T (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SE FRANK PHILLIPS
Mailing Address - Street 2:STE 502
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2495
Mailing Address - Country:US
Mailing Address - Phone:918-331-2577
Mailing Address - Fax:918-331-2513
Practice Address - Street 1:3400 SE FRANK PHILLIPS #502
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006
Practice Address - Country:US
Practice Address - Phone:918-331-2577
Practice Address - Fax:918-331-2513
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3077207RC0000X
KS0524469207RC0000X
KS05-24469207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100106620AMedicaid
KS101863Medicaid
KS100232630BMedicare PIN
OK100106620AMedicaid
OK$$$$$$$$$RMedicare PIN