Provider Demographics
NPI:1689615536
Name:DYKSTRA, MANDIE LEE (MD)
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:LEE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 VENTURI DR
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-8931
Mailing Address - Country:US
Mailing Address - Phone:956-873-3769
Mailing Address - Fax:
Practice Address - Street 1:1920 E GRIFFIN PKWY
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3106
Practice Address - Country:US
Practice Address - Phone:956-584-3353
Practice Address - Fax:956-584-3253
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine