Provider Demographics
NPI:1154361558
Name:DYSART, JEFFREY H (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:H
Last Name:DYSART
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:PO BOX 710488
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92171-0488
Mailing Address - Country:US
Mailing Address - Phone:858-268-1111
Mailing Address - Fax:858-268-0761
Practice Address - Street 1:3880 MURPHY CANYON RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4411
Practice Address - Country:US
Practice Address - Phone:858-268-1111
Practice Address - Fax:858-268-0761
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7362731Medicaid
A28247Medicare UPIN
A36992Medicare ID - Type Unspecified