Provider Demographics
NPI:1659365518
Name:DYKSTRA, ELIZABETH P (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:P
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:D
Other - Last Name:PONDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:1622 WESTGATE CIR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8019
Practice Address - Country:US
Practice Address - Phone:629-255-2095
Practice Address - Fax:629-255-4107
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35225208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1502891Medicaid
TN1502891Medicaid
H35576Medicare UPIN