Basic Information
| Provider Information | |||||||||
| NPI: | 1508866302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HYDE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 DAYTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677291 | ||||||||
| FaxNumber: | 9377671302 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 DAYTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677291 | ||||||||
| FaxNumber: | 9377671302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35055374 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0680222 | 05 | OH | MEDICAID | 000000025871 | 01 | OH | ANTHEM | OTHER |