Healthcare Provider Details

I. General information

NPI: 1285835769
Provider Name (Legal Business Name): DIVINA N DYER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 S PARK ST
CARROLLTON GA
30117-4450
US

IV. Provider business mailing address

1128 S PARK ST
CARROLLTON GA
30117-4450
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-0870
  • Fax: 770-836-1873
Mailing address:
  • Phone: 770-836-0870
  • Fax: 770-836-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number057161
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: