Provider Demographics
NPI:1154457018
Name:VAN DYKE, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:VAN DYKE
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 1:5206 N SCOTTSDALE RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-7006
Mailing Address - Country:US
Mailing Address - Phone:480-948-5045
Mailing Address - Fax:480-948-5605
Practice Address - Street 1:5206 N SCOTTSDALE RD
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-7006
Practice Address - Country:US
Practice Address - Phone:480-948-5045
Practice Address - Fax:480-948-5605
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20156207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology