Provider Demographics
NPI:1114957727
Name:DYBALL, MARK EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:DYBALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7383
Mailing Address - Country:US
Mailing Address - Phone:810-953-0500
Mailing Address - Fax:810-953-0031
Practice Address - Street 1:861 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-953-0500
Practice Address - Fax:810-953-0031
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009577207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3166333Medicaid
MI3166333Medicaid
MIF59740Medicare UPIN