Provider Demographics
NPI:1124050562
Name:DY, JOHNNY (MD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:DY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 S KANAWHA STREET
Mailing Address - Street 2:
Mailing Address - City:BECKLY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3637
Mailing Address - Country:US
Mailing Address - Phone:304-252-0699
Mailing Address - Fax:304-255-6719
Practice Address - Street 1:401 S KANAWHA STREET
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3637
Practice Address - Country:US
Practice Address - Phone:304-252-0699
Practice Address - Fax:304-255-6719
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV100722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0089998000Medicaid
WV0402311Medicare ID - Type Unspecified
D49211Medicare UPIN