Healthcare Provider Details

I. General information

NPI: 1174773485
Provider Name (Legal Business Name): JUSTIN M HYDE R.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
BILOXI MS
39534
US

IV. Provider business mailing address

301 FISHER ST
BILOXI MS
39534-2508
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-5072
  • Fax:
Mailing address:
  • Phone: 228-376-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1001941
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0116028175
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: