Healthcare Provider Details

I. General information

NPI: 1720064512
Provider Name (Legal Business Name): JOHN B DYMOND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

5767 COBBLESTONE DR
OSAGE BEACH MO
65065-2477
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-8000
  • Fax:
Mailing address:
  • Phone: 573-480-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number106105
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier203906508
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: