1619988763 NPI number — MAYNARD C DYSON MD

Table of content: MAYNARD C DYSON MD (NPI 1619988763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619988763 NPI number — MAYNARD C DYSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYSON
Provider First Name:
MAYNARD
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619988763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76199-0371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-885-1855
Provider Business Mailing Address Fax Number:
682-885-7347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 COOPER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-885-6299
Provider Business Practice Location Address Fax Number:
682-885-1090
Provider Enumeration Date:
08/11/2006

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: 2080P0214X , with the licence number:  H9069 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1392667 . This is a "UHC PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1485631 . This is a "CIGNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 136186712 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140442845 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1640370 . This is a "FIRSTHEALTH PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 136186714 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136186715 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4613484 . This is a "AETNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 62741133 . This is a "MULTIPLAN PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00U87Z . This is a "BCBSTX GRP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112070100 . This is a "FIRSTCARE PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 136186713 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 386710 . This is a "GREAT WEST PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 413449 . This is a "PHCS PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10028696 . This is a "AMERIGROUP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 109539 . This is a "SUPERIOR PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 89V243 . This is a "BCBSTX IND PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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