Provider Demographics
NPI:1083695886
Name:NYSTROM, PERRY G (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:G
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428-9000
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:937-267-3917
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:937-267-3917
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062875207L00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF31283Medicare UPIN