Provider Demographics
NPI:1376591073
Name:DYER, JONATHAN A (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1101 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-4800
Practice Address - Fax:573-884-5947
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014980207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO189164OtherBLUE SHIELD/BLUE CHOICE
MO658400OtherHEALTHLINK
MO209312404Medicaid
MO300639OtherUNITED HEALTHCARE
MOP00419155Medicare PIN
MO927031443Medicare PIN
MO300639OtherUNITED HEALTHCARE
MOP00186644Medicare PIN
I25600Medicare UPIN