Basic Information
| Provider Information | |||||||||
| NPI: | 1710913645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYRUD | ||||||||
| FirstName: | MARTINUS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9400 TURKEY LAKE RD # MP452 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435177 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 TURKEY LAKE RD # MP452 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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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 | 207R00000X | DOS-1079 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OS12476 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0000254227 | 01 | HI | HMSA BILLING NUMBER | OTHER | 572744-01 | 05 | HI | MEDICAID |