Healthcare Provider Details

I. General information

NPI: 1619903226
Provider Name (Legal Business Name): PETER ALLEN DYSERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 GASTON AVE WADLEY TOWER, SUITE 261
DALLAS TX
75246-1800
US

IV. Provider business mailing address

3600 GASTON AVE BARNETT TOWER, SUITE 707
DALLAS TX
75246-1800
US

V. Phone/Fax

Practice location:
  • Phone: 214-818-9100
  • Fax: 214-818-9180
Mailing address:
  • Phone: 214-823-6492
  • Fax: 214-818-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG0693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: