Provider Demographics
NPI:1659318673
Name:VAN DYKE, GERALD (GERRY) C (PT)
Entity Type:Individual
Prefix:
First Name:GERALD (GERRY)
Middle Name:C
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6193 SOQUEL DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3116
Mailing Address - Country:US
Mailing Address - Phone:831-462-1212
Mailing Address - Fax:831-462-1221
Practice Address - Street 1:6193 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3116
Practice Address - Country:US
Practice Address - Phone:831-462-1212
Practice Address - Fax:831-462-1221
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT131812251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA650009364OtherRAILROAD MEDICARE
CA770393462OtherBLUE CROSS
CAPT0131810Medicaid
CAZZZ45601ZOtherBLUE SHIELD
CAPT0131810Medicaid