Provider Demographics
NPI:1821084443
Name:VAN DYKE, BYRON JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:JAMES
Last Name:VAN DYKE
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:PO BOX 994505
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-4505
Mailing Address - Country:US
Mailing Address - Phone:530-247-7546
Mailing Address - Fax:530-247-7228
Practice Address - Street 1:1158 N COURT ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0436
Practice Address - Country:US
Practice Address - Phone:530-247-7546
Practice Address - Fax:530-247-7228
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69012207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A690120Medicaid
CAH30706Medicare UPIN
CA00A690120Medicaid