Provider Demographics
NPI:1952309163
Name:DYSTER, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:DYSTER
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 1:4600 MILITARY RD STE A
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14305-1338
Mailing Address - Country:US
Mailing Address - Phone:716-298-4050
Mailing Address - Fax:716-298-4098
Practice Address - Street 1:4600 MILITARY RD STE A
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-1338
Practice Address - Country:US
Practice Address - Phone:716-298-4050
Practice Address - Fax:716-298-4098
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01023394Medicaid
CACA236553Medicare PIN
NY01023394Medicare ID - Type Unspecified
NYB71426Medicare UPIN