Provider Demographics
NPI:1477060218
Name:DYKES MEDICAL PLLC
Entity type:Organization
Organization Name:DYKES MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GERRIT
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-695-9464
Mailing Address - Street 1:102 LOBLOLLY LN NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-9217
Mailing Address - Country:US
Mailing Address - Phone:601-695-9464
Mailing Address - Fax:601-823-6777
Practice Address - Street 1:101 MILLS ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2521
Practice Address - Country:US
Practice Address - Phone:601-833-5608
Practice Address - Fax:601-823-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS15940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124038Medicaid