Provider Demographics
NPI:1083145692
Name:DYSTER, TIMOTHY GORDON
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GORDON
Last Name:DYSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HAVEN AVE
Mailing Address - Street 2:APT 27G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2645
Mailing Address - Country:US
Mailing Address - Phone:716-523-6958
Mailing Address - Fax:
Practice Address - Street 1:100 HAVEN AVE
Practice Address - Street 2:APT 27G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2645
Practice Address - Country:US
Practice Address - Phone:716-523-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program