Provider Demographics
NPI:1891882973
Name:DYKYJ, ROMAN JR (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:DYKYJ
Suffix:JR
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 1:8151 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3002
Mailing Address - Country:US
Mailing Address - Phone:215-624-3000
Mailing Address - Fax:215-624-6855
Practice Address - Street 1:8151 REVERE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3002
Practice Address - Country:US
Practice Address - Phone:215-624-3000
Practice Address - Fax:215-624-6855
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027187E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0054192000OtherINDEPENDENT BLUE CROSS
PAA00995OtherAMERIHEALTH ADMINISTRATOR
PA2061288OtherAETNA
PA0054192001OtherKEYSTONE HPE
PAA00995OtherAMERIHEALTH ADMINISTRATOR
PAE71569Medicare UPIN