Provider Demographics
NPI:1578566527
Name:DYSART, STANLEY H (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:H
Last Name:DYSART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 TOWER RD NE
Mailing Address - Street 2:STE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9403
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-429-6503
Practice Address - Street 1:300 TOWER RD NE
Practice Address - Street 2:STE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9403
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-429-6503
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA031591207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE80424Medicare UPIN
GA20BBCZLMedicare ID - Type Unspecified