Provider Demographics
NPI:1285835769
Name:DYER, DIVINA N (MD)
Entity Type:Individual
Prefix:
First Name:DIVINA
Middle Name:N
Last Name:DYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 CLEVELAND AVE SW STE 604
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7116
Mailing Address - Country:US
Mailing Address - Phone:404-305-0004
Mailing Address - Fax:404-305-0494
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:800-827-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
08-18-1978OtherBIRTHDATE