Provider Demographics
NPI:1831151596
Name:DYKSTERHOUSE, ANDREW J (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:DYKSTERHOUSE
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 1:1220 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3370
Mailing Address - Country:US
Mailing Address - Phone:704-825-5333
Mailing Address - Fax:704-825-1751
Practice Address - Street 1:1220 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3370
Practice Address - Country:US
Practice Address - Phone:704-825-5333
Practice Address - Fax:704-825-1751
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137MHMedicaid
NCP00393599OtherRAILROAD MEDICARE
NC2028501AMedicare PIN
NCP00393599OtherRAILROAD MEDICARE