Basic Information
| Provider Information | |||||||||
| NPI: | 1558725051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYKEMA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RUSSEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6363 FOREST PARK RD,7TH FLOOR STE749 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753902500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458500 | ||||||||
| FaxNumber: | 2146452632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | S6606 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.