Provider Demographics
NPI:1265487284
Name:DYKES, SHARON LUSTER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:LUSTER
Last Name:DYKES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHARON
Other - Middle Name:MICHELLE
Other - Last Name:LUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2355 FAIRVIEW AVE N
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2724
Mailing Address - Country:US
Mailing Address - Phone:612-293-9977
Mailing Address - Fax:612-293-9988
Practice Address - Street 1:910 E 26TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4526
Practice Address - Country:US
Practice Address - Phone:612-293-9977
Practice Address - Fax:612-293-9988
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40267208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN939623300Medicaid
MN939623300Medicaid
MNH87954Medicare UPIN