Provider Demographics
NPI:1982701587
Name:DYKUN, ROMAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:J
Last Name:DYKUN
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 1:2441 LAKE SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098
Mailing Address - Country:US
Mailing Address - Phone:815-338-4600
Mailing Address - Fax:815-338-4611
Practice Address - Street 1:2441 LAKE SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-338-4600
Practice Address - Fax:815-338-4611
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063771207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063771Medicaid
ILCN5830Medicare PIN
C45570Medicare UPIN
IL040016676Medicare PIN
IL040000388Medicare PIN
IL036063771Medicaid
ILK19257Medicare ID - Type UnspecifiedLOCALITY 15
ILK19256Medicare ID - Type UnspecifiedLOCALITY 99