Provider Demographics
NPI:1033199674
Name:DYK, RANDALL L (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:DYK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5629 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1952
Mailing Address - Country:US
Mailing Address - Phone:269-372-1000
Mailing Address - Fax:269-372-0698
Practice Address - Street 1:5629 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-1000
Practice Address - Fax:269-372-0698
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076181208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4630842Medicaid
MICA4396OtherRAILROAD MEDICARE
MI4526826Medicaid
MI4526826Medicaid
MIM20520034Medicare PIN