Provider Demographics
NPI:1730275470
Name:VAN DYCK, PETER BERN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BERN
Last Name:VAN DYCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:BERN
Other - Last Name:DYCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 80155
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27623-0155
Mailing Address - Country:US
Mailing Address - Phone:919-781-1800
Mailing Address - Fax:919-781-1899
Practice Address - Street 1:4601 LAKE BOONE TRL STE 1B
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7503
Practice Address - Country:US
Practice Address - Phone:919-781-1800
Practice Address - Fax:919-781-1899
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC271652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC83604Medicare UPIN
NCC83604Medicare UPIN