Provider Demographics
NPI:1609004308
Name:DYKHUIZEN, MATTHEW J (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:DYKHUIZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2865 CHANCELLOR DR
Mailing Address - Street 2:STE 215
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3931
Mailing Address - Country:US
Mailing Address - Phone:859-344-2079
Mailing Address - Fax:859-581-7207
Practice Address - Street 1:2865 CHANCELLOR DR
Practice Address - Street 2:SUITE 215
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3912
Practice Address - Country:US
Practice Address - Phone:859-344-2079
Practice Address - Fax:859-581-7207
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128411207W00000X, 207WX0107X
KY46137207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110825Medicaid
KY7100243970Medicaid
KYK103712Medicare PIN
OHH492881Medicare PIN
KYK103711Medicare PIN
OHH492880Medicare PIN
OH0110825Medicaid