Provider Demographics
NPI:1710916341
Name:DYKSTRA, KENNETH D (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 E MURDOCK ST
Mailing Address - Street 2:SUITE #500
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3052
Mailing Address - Country:US
Mailing Address - Phone:316-962-2080
Mailing Address - Fax:316-962-2079
Practice Address - Street 1:3243 E MURDOCK ST
Practice Address - Street 2:SUITE #500
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3052
Practice Address - Country:US
Practice Address - Phone:316-962-2080
Practice Address - Fax:316-962-2079
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS280932080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12149357OtherMULTIPLAN
KS055541OtherBCBS
KS200626OtherHPK
KS11872OtherPHS
KS100333960AMedicaid
KS16997OtherCOVENTRY
KS055541Medicare ID - Type Unspecified
KS16997OtherCOVENTRY