Provider Demographics
NPI:1184621021
Name:DYESS, DEREK S (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:DYESS
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 1:1860 CHADWICK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3463
Mailing Address - Country:US
Mailing Address - Phone:601-373-6441
Mailing Address - Fax:601-373-5715
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-373-6441
Practice Address - Fax:601-373-5715
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3296112085R0202X
VT042.0016510-COMP2085R0202X
MS171312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07804294Medicaid
MSP00122992OtherRAILROAD MEDICARE
MS07804294Medicaid
MS300000885Medicare ID - Type Unspecified
MS300000885Medicare PIN