Provider Demographics
NPI:1376592758
Name:DYKSTRA, TIMOTHY J (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-216207R00000X
WAOP00001634207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376592758Medicaid
1301846OtherDMERC
WA1008949Medicaid
WA128877OtherLABOR & INDUSTRY
ID1376592758OtherREGENCE BLUE SHIELD
ID110184432OtherRR MEDICARE
IDS3028OtherBLUE CROSS OF IDAHO
ID1376592758Medicaid
ID1376592758OtherREGENCE BLUE SHIELD
WA1008949Medicaid