1194710202 NPI number — MICHELE A DYAN MD

Table of content: MICHELE A DYAN MD (NPI 1194710202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194710202 NPI number — MICHELE A DYAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYAN
Provider First Name:
MICHELE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DYAN-MCMICHAEL
Provider Other First Name:
MICHELE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1194710202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
977 48TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11219-2919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-283-8015
Provider Business Mailing Address Fax Number:
718-635-7235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4802 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11219-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-283-8853
Provider Business Practice Location Address Fax Number:
718-635-7235
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  183542 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 183542 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 183542-A15 . This is a "HEALTH FIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 550291 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P1010725 . This is a "OXFORD HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01371140 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2699528 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: BK00944-03 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C4441 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1861255 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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