Provider Demographics
NPI:1467413070
Name:VAN DYKE, TRAVIS BOYD (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:BOYD
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W CRYSTAL LAKE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4475
Mailing Address - Country:US
Mailing Address - Phone:407-254-2500
Mailing Address - Fax:407-254-2557
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:STE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:407-254-2500
Practice Address - Fax:407-254-2557
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92680207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8671773OtherCIGNA
FLI34131Medicare UPIN
FLU5065ZMedicare PIN