Healthcare Provider Details

I. General information

NPI: 1265425177
Provider Name (Legal Business Name): JOHN M DYSART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/20/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 DISCOVERY DRIVE SUITE 210
LANSING MI
48910
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 517-484-0004
  • Fax: 517-484-7241
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberJD063672
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: