Provider Demographics
NPI:1427223916
Name:DYKES, MARK DWAYNE (SFIDC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DWAYNE
Last Name:DYKES
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-7800
Mailing Address - Country:US
Mailing Address - Phone:951-927-9142
Mailing Address - Fax:
Practice Address - Street 1:700 COLORADO DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544
Practice Address - Country:US
Practice Address - Phone:951-927-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman