Provider Demographics
NPI:1518971092
Name:DYKEWICZ, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:DYKEWICZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1402 S GRAND BLVD
Mailing Address - Street 2:M157
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-977-8828
Mailing Address - Fax:314-977-8816
Practice Address - Street 1:3691 RUTGER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2515
Practice Address - Country:US
Practice Address - Phone:314-977-9050
Practice Address - Fax:314-977-9770
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2015-04-01
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Provider Licenses
StateLicense IDTaxonomies
MOR3N72207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00724310OtherRAILROAD MEDICARE
SCQ70000Medicaid
NC2023448Medicare PIN
VA1518971092Medicaid
NC5911105Medicaid