Provider Demographics
NPI:1528019338
Name:VAN DYKE, JAMES MARTIN (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARTIN
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-1902
Mailing Address - Country:US
Mailing Address - Phone:937-845-0260
Mailing Address - Fax:937-845-0262
Practice Address - Street 1:110 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344-1902
Practice Address - Country:US
Practice Address - Phone:937-845-0260
Practice Address - Fax:937-845-0262
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT003617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2627385Medicaid
OH4175121Medicare PIN