Provider Demographics
NPI:1740253277
Name:DYKSTRA, ARTHUR M (DO)
Entity type:Individual
Prefix:
First Name:ARTHUR
Middle Name:M
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:A.
Other - Middle Name:MICHAEL
Other - Last Name:DYKSTRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1100 E OUTER RD S
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1702
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4038
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240189902Medicaid
MO003012751Medicare PIN
IL080070199Medicare PIN
D41680Medicare UPIN
IL202625Medicare PIN