Provider Demographics
NPI:1619988763
Name:DYSON, MAYNARD C (MD)
Entity Type:Individual
Prefix:
First Name:MAYNARD
Middle Name:C
Last Name:DYSON
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 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-6299
Practice Address - Fax:682-885-1090
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH90692080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1392667OtherUHC PIN
TX1485631OtherCIGNA PIN
TX136186712Medicaid
TX140442845Medicaid
TX1640370OtherFIRSTHEALTH PIN
TX136186714Medicaid
TX136186715OtherCSHCN
TX4613484OtherAETNA PIN
TX62741133OtherMULTIPLAN PIN
TX00U87ZOtherBCBSTX GRP PIN
TX112070100OtherFIRSTCARE PIN
TX136186713OtherCSHCN
TX386710OtherGREAT WEST PIN
TX413449OtherPHCS PIN
TX10028696OtherAMERIGROUP PIN
TX109539OtherSUPERIOR PIN
TX89V243OtherBCBSTX IND PIN
TX89V243OtherBCBSTX IND PIN
TX386710OtherGREAT WEST PIN