Provider Demographics
NPI:1629123716
Name:DYSART, AMY R (MD)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:R
Last Name:DYSART
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 1:2457 N MAYFAIR RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1405
Mailing Address - Country:US
Mailing Address - Phone:414-476-0306
Mailing Address - Fax:414-476-7720
Practice Address - Street 1:2457 N MAYFAIR RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1405
Practice Address - Country:US
Practice Address - Phone:414-476-0306
Practice Address - Fax:414-476-7720
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-165653207V00000X
WI43777207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
73823Medicare ID - Type Unspecified
I20618Medicare UPIN