Provider Demographics
NPI:1528019403
Name:DYCKMAN, RICHARD HARRIS (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HARRIS
Last Name:DYCKMAN
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 1:285 SILLS ROAD
Mailing Address - Street 2:BUILDING # 14
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-447-8300
Mailing Address - Fax:631-447-8872
Practice Address - Street 1:285 SILLS ROAD
Practice Address - Street 2:BUILDING # 14
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-447-8300
Practice Address - Fax:631-447-8872
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166642207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01147204Medicaid
NY17F031Medicare ID - Type Unspecified
D92014Medicare UPIN