Provider Demographics
NPI:1437198918
Name:VANDYKEN, RICHARD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:VANDYKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:ALAN
Other - Last Name:VAN DYKEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:426 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5609
Practice Address - Country:US
Practice Address - Phone:616-267-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460227Medicare PIN
MI0D16150022Medicare ID - Type Unspecified
F37557Medicare UPIN