Basic Information
Provider Information | |||||||||
NPI: | 1548203433 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DYER | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | WAYNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 927 IRONWOOD DR | ||||||||
Address2: |   | ||||||||
City: | DESOTO | ||||||||
State: | TX | ||||||||
PostalCode: | 751152127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726687460 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 928 LIPSCOMB ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761043171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173488600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 09/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | L3629 | TX | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208VP0000X | L3629 | TX | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 0022NG | 01 | TX | BCBS | OTHER |