Provider Demographics
NPI:1952408346
Name:DYSERT, GERALD A (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:DYSERT
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 1:1709 KY ROUTE 321
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9097
Mailing Address - Country:US
Mailing Address - Phone:606-886-8546
Mailing Address - Fax:606-886-8548
Practice Address - Street 1:23 WILLOW DR
Practice Address - Street 2:
Practice Address - City:AUXIER
Practice Address - State:KY
Practice Address - Zip Code:41602-9259
Practice Address - Country:US
Practice Address - Phone:606-886-8997
Practice Address - Fax:606-886-1021
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34177207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000044263OtherBCBS PROVIDER NUMBER
KY34177OtherLICENSE
KY64341779Medicaid
KY160048896Medicare PIN
0691609Medicare PIN
0375320Medicare PIN
0374723Medicare UPIN
0375222Medicare PIN
0376168Medicare PIN
0525621Medicare PIN
F09311Medicare UPIN
0375070Medicare PIN
000000044263OtherBCBS PROVIDER NUMBER
KYK009460Medicare PIN