Basic Information
| Provider Information | |||||||||
| NPI: | 1952411860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYBEDOCK | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 10763 HIGHWAY 39 | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657127823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692460 | ||||||||
| FaxNumber: | 4172692462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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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 | 2004036071 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208386904 | 05 | MO | MEDICAID | 195977 | 01 | BLUE CROSS MO | OTHER |