Provider Demographics
NPI:1124129788
Name:DYM, JEFFREY MERRICK (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MERRICK
Last Name:DYM
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:DEPT LA 21789
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1789
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:25500 RANCHO NIGUEL ROAD, SUITE 120
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:62677
Practice Address - Country:US
Practice Address - Phone:949-831-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA939602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A939600OtherBS OF CA
CA1124129788Medicaid
H89026Medicare UPIN
CA1124129788Medicaid