Provider Demographics
NPI:1629151766
Name:DYKSTRA, RICHARD J (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6956 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482
Mailing Address - Country:US
Mailing Address - Phone:708-361-1570
Mailing Address - Fax:708-448-5074
Practice Address - Street 1:6956 W 111TH ST
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482
Practice Address - Country:US
Practice Address - Phone:708-361-1570
Practice Address - Fax:708-448-5074
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046 007176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL025963001OtherADMINASTAR FEDERAL
T37615Medicare UPIN
IL025963001OtherADMINASTAR FEDERAL
IL663200Medicare PIN