Provider Demographics
NPI:1649231051
Name:DYCK, DAVID D JR (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:DYCK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19550 E 39TH ST S STE 230
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2309
Mailing Address - Country:US
Mailing Address - Phone:816-795-8200
Mailing Address - Fax:816-795-7735
Practice Address - Street 1:19550 E 39TH ST S
Practice Address - Street 2:SUITE 419
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2358
Practice Address - Country:US
Practice Address - Phone:816-795-8200
Practice Address - Fax:816-795-7735
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108810207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100396370BMedicaid
KS100396370CMedicaid
MO1649231051Medicaid
MO080135929OtherRAILROAD MEDICARE
KSF829728Medicare ID - Type Unspecified
MOMA1431001Medicare PIN
G41991Medicare UPIN
MOP00703587Medicare PIN