Provider Demographics
NPI:1780601708
Name:DYCUS, DOUGLAS C (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:C
Last Name:DYCUS
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 247
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-0247
Mailing Address - Country:US
Mailing Address - Phone:931-268-3224
Mailing Address - Fax:931-268-3228
Practice Address - Street 1:3698 S GRUNDY QUARLES HWY
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-5950
Practice Address - Country:US
Practice Address - Phone:931-268-3224
Practice Address - Fax:931-268-3228
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD020847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3057264Medicaid
TN142892OtherBC/BSTN
TNE81387Medicare UPIN
TN3057264Medicare PIN