Basic Information
| Provider Information | |||||||||
| NPI: | 1447496781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKOSKI | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | NIX | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7136204098 | ||||||||
| Practice Location | |||||||||
| Address1: | 2411 FOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770574817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7136204098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 10/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N3017 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8CD179 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 206775301 | 05 | TX | MEDICAID | P00845809 | 01 | TX | RAILROAD MEDICARE | OTHER |