Healthcare Provider Details

I. General information

NPI: 1124129788
Provider Name (Legal Business Name): JEFFREY MERRICK DYM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 RANCHO NIGUEL ROAD, SUITE 120
LAGUNA NIGUEL CA
62677
US

IV. Provider business mailing address

DEPT LA 21789
PASADENA CA
91185-1789
US

V. Phone/Fax

Practice location:
  • Phone: 949-831-3122
  • Fax:
Mailing address:
  • Phone: 949-263-8620
  • Fax: 800-409-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA93960
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: