Provider Demographics
NPI:1841328614
Name:VAN DYKE, GREGORY S (MD, PHD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12409 VENTURA CT
Mailing Address - Street 2:STE C
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2471
Mailing Address - Country:US
Mailing Address - Phone:818-900-6007
Mailing Address - Fax:818-900-6607
Practice Address - Street 1:12409 VENTURA CT
Practice Address - Street 2:STE C
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2471
Practice Address - Country:US
Practice Address - Phone:818-900-6007
Practice Address - Fax:818-900-6607
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81049207ZD0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A810490Medicaid
CA00A810490Medicaid
CAWA81049AMedicare PIN