Provider Demographics
NPI:1528221785
Name:VAN DYKEN, IRMINNE GELDERLOOS (MD)
Entity Type:Individual
Prefix:MRS
First Name:IRMINNE
Middle Name:GELDERLOOS
Last Name:VAN DYKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRMINNE
Other - Middle Name:
Other - Last Name:GELDERLOOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:80 MAHALANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2531
Mailing Address - Country:US
Mailing Address - Phone:808-243-6000
Mailing Address - Fax:
Practice Address - Street 1:80 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2531
Practice Address - Country:US
Practice Address - Phone:808-243-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDTRL 10940208600000X
ND12890208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN718980Medicare UPIN