Provider Demographics
NPI:1053303479
Name:DYCK, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:DYCK
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:3301 COUNTY ROAD 6 E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-7673
Practice Address - Country:US
Practice Address - Phone:574-264-9635
Practice Address - Fax:574-262-0398
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067738A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200989420Medicaid
IN236040061OtherMEDICARE PTAN
OHKN9353961Medicare ID - Type Unspecified
IN200989420Medicaid
INP00867326Medicare PIN
INM400021035Medicare PIN
OHI30638Medicare UPIN
IN000000665110OtherANTHEM BCBS
INM400021035Medicare PIN
INP00867326Medicare PIN
OH202398959OtherMED BEN
OHI30638Medicare UPIN