Provider Demographics
NPI:1477534741
Name:DYSTER, TIMOTHY GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:DYSTER
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:PO BOX 8000 DEPT 570
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:716-298-2356
Mailing Address - Fax:
Practice Address - Street 1:5300 MILITARY RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1903
Practice Address - Country:US
Practice Address - Phone:716-298-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174697-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01210604Medicaid
NYE28174Medicare UPIN
NY01210604Medicaid