Provider Demographics
NPI:1194710202
Name:DYAN, MICHELE A (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:DYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:A
Other - Last Name:DYAN-MCMICHAEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:977 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2919
Mailing Address - Country:US
Mailing Address - Phone:718-283-8015
Mailing Address - Fax:718-635-7235
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2844
Practice Address - Country:US
Practice Address - Phone:718-283-8853
Practice Address - Fax:718-635-7235
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1835422080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY183542OtherHIP
NY183542-A15OtherHEALTH FIRST
NY550291OtherEMPIRE BCBS
NYP1010725OtherOXFORD HEALTH PLANS
NY01371140Medicaid
NY2699528OtherGHI
NYBK00944-03OtherAMERICHOICE
NY4C4441OtherHEALTH NET
NY1861255OtherUNITED HEALTH CARE
NY550291Medicare ID - Type Unspecified
NY2699528OtherGHI