Provider Demographics
NPI:1093211948
Name:DYER, JUSTIN DEANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEANTHONY
Last Name:DYER
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5500
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4550 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5817
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-256-7872
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA325979207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine