Provider Demographics
NPI:1215029483
Name:DYM, JACK H (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:H
Last Name:DYM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3050 E AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2404
Mailing Address - Country:US
Mailing Address - Phone:562-426-9661
Mailing Address - Fax:562-426-4227
Practice Address - Street 1:10200 SEPULVEDA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2649
Practice Address - Country:US
Practice Address - Phone:818-893-6949
Practice Address - Fax:818-892-2546
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG18786207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G187860OtherMEDI-CAL