Provider Demographics
NPI:1821042391
Name:DYER, THEODORE C (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:C
Last Name:DYER
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 1198
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-1198
Mailing Address - Country:US
Mailing Address - Phone:325-670-4220
Mailing Address - Fax:325-670-4040
Practice Address - Street 1:1900 PINE ST
Practice Address - Street 2:ROOM 4653
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2432
Practice Address - Country:US
Practice Address - Phone:325-670-3500
Practice Address - Fax:325-670-4773
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2949207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123067OtherSUPERIOR
TX040011721OtherRRMEDICARE
TX112066105OtherFIRSTCARE
TX0073PJOtherBLUE CROSS
TX126206506Medicaid
TX126206506Medicaid
TX00DA94Medicare PIN