Provider Demographics
NPI:1255321808
Name:DYER, RAYMOND EARL (PT)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:EARL
Last Name:DYER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12320 HIGHWAY 44 BLDG 3F
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2202
Mailing Address - Country:US
Mailing Address - Phone:225-647-9505
Mailing Address - Fax:225-647-9503
Practice Address - Street 1:12320 HIGHWAY 44 BLDG 3F
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2202
Practice Address - Country:US
Practice Address - Phone:225-647-9505
Practice Address - Fax:225-647-9503
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04375R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7981142OtherAETNA NON HMO PROVIDER#
LA1114103Medicaid
LA2513209OtherAETNA HMO PROVIDER#
LA4B712Medicare ID - Type UnspecifiedMEDICARE PROVIDER#