Healthcare Provider Details

I. General information

NPI: 1619988763
Provider Name (Legal Business Name): MAYNARD C DYSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COOPER ST
FORT WORTH TX
76104-2710
US

IV. Provider business mailing address

PO BOX 99371
FORT WORTH TX
76199-0371
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6299
  • Fax: 682-885-1090
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberH9069
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: