Basic Information
| Provider Information | |||||||||
| NPI: | 1215949599 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DYE | ||||||||
| FirstName: | DERRY | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737852005 | ||||||||
| FaxNumber: | 5737859444 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737852005 | ||||||||
| FaxNumber: | 5737859444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | R5G11 | MO | N | Allopathic & Osteopathic Physicians | General Practice | 208000000X | R5G11 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 202400024 | 05 | MO | MEDICAID |