Provider Demographics
NPI:1497708580
Name:DYCK, ERIC LEE (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LEE
Last Name:DYCK
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 1:2102 BAPTISTE DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1314
Mailing Address - Country:US
Mailing Address - Phone:913-557-5678
Mailing Address - Fax:913-557-5681
Practice Address - Street 1:2102 BAPTISTE DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1314
Practice Address - Country:US
Practice Address - Phone:913-557-5678
Practice Address - Fax:913-557-5681
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0418590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100420290AMedicaid
B68525Medicare UPIN
KS102127Medicare ID - Type Unspecified