Provider Demographics
NPI:1841485018
Name:DYER, CRYSTAL SHANELLE (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHANELLE
Last Name:DYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:SHANELLE
Other - Last Name:CARAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 W MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-3663
Mailing Address - Country:US
Mailing Address - Phone:423-500-0266
Mailing Address - Fax:
Practice Address - Street 1:850 W MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3663
Practice Address - Country:US
Practice Address - Phone:423-500-0266
Practice Address - Fax:423-500-4280
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247662207QS0010X, 207QS0010X
TN44247207QS0010X, 207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44247OtherSTATE MEDICAL LICENSE
TNFD4444155OtherDEA - MORRISTOWN CENTER FOR WELLNESS
TNFD4444179OtherDEA - SEVIERVILLE CENTER FOR WELLNESS
TNFD4444193OtherDEA - ROGERSVILLE CENTER FOR WELLNESS
TNFD1326974OtherDEA - REVIVE WELLNESS
TNFD4444155OtherDEA - MORRISTOWN CENTER FOR WELLNESS
TNFD4444179OtherDEA - SEVIERVILLE CENTER FOR WELLNESS
TNFD3339202OtherDEA - GREENEVILLE IN SHAPE HEALTH CENTER
TNFD3339187OtherDEA - BRISTOL IN SHAPE WEIGHT LOSS CLINIC
TNFD3707710OtherDEA - TAZEWELL IN SHAPE WEIGHT LOSS CLINIC