Healthcare Provider Details

I. General information

NPI: 1366641789
Provider Name (Legal Business Name): BRADLEY W DYRSTAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKS LEGADO CT
ODESSA TX
79765-2542
US

IV. Provider business mailing address

1 PARKS LEGADO CT
ODESSA TX
79765-2542
US

V. Phone/Fax

Practice location:
  • Phone: 432-332-2663
  • Fax: 432-335-8849
Mailing address:
  • Phone: 432-332-2663
  • Fax: 432-335-8849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35.099289
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number60790
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number125-052536
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberP4440
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: