Provider Demographics
NPI:1528274503
Name:VYAS, DINESH (MD)
Entity type:Individual
Prefix:DR
First Name:DINESH
Middle Name:
Last Name:VYAS
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 1:9717 RUDDY DUCK WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8155
Mailing Address - Country:US
Mailing Address - Phone:314-260-7609
Mailing Address - Fax:314-260-7609
Practice Address - Street 1:3133 W MARCH LN STE 1040B
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2360
Practice Address - Country:US
Practice Address - Phone:314-260-7609
Practice Address - Fax:517-267-2462
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.011768208600000X
MO2009006855208600000X
MI4301099055208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9810335OtherAETNA
MI1528274503Medicaid
MO9810335OtherAETNA
MI1528274503Medicaid
MA2899Medicare PIN