Provider Demographics
NPI:1093211948
Name:DYER, JUSTIN DEANTHONY (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEANTHONY
Last Name:DYER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4451 HWY 1 S STE 5
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-5907
Mailing Address - Country:US
Mailing Address - Phone:252-763-4852
Mailing Address - Fax:225-763-4853
Practice Address - Street 1:4451 HWY 1 S STE 5
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-5907
Practice Address - Country:US
Practice Address - Phone:225-763-4852
Practice Address - Fax:228-763-4853
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA325979207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine