Provider Demographics
NPI:1104827625
Name:VANVALKENBURG, DYRK A (MD)
Entity Type:Individual
Prefix:
First Name:DYRK
Middle Name:A
Last Name:VANVALKENBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:20 OVERBROOK DR
Practice Address - Street 2:UNIT C
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-3101
Practice Address - Country:US
Practice Address - Phone:513-539-7356
Practice Address - Fax:513-539-7782
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-07-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH51770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0602735Medicaid
OHA16242Medicare UPIN
OHH222820Medicare PIN
OHVA0573992Medicare PIN