Basic Information
Provider Information
NPI: 1003143256
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DIKE
FirstName: CHARLES
MiddleName: OKECHUKWU
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1680 DIAGONAL RD
Address2:  
City: WORTHINGTON
State: MN
PostalCode: 561871008
CountryCode: US
TelephoneNumber: 5073723800
FaxNumber:  
Practice Location
Address1: 1680 DIAGONAL RD
Address2:  
City: WORTHINGTON
State: MN
PostalCode: 561871008
CountryCode: US
TelephoneNumber: 5073723800
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/09/2009
LastUpdateDate: 11/09/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X46539MNY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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