Provider Demographics
NPI:1588875827
Name:DYNIEWSKI, JUSTIN MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:DYNIEWSKI
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 1:1527 HEMPHILL ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4706
Mailing Address - Country:US
Mailing Address - Phone:817-569-5900
Mailing Address - Fax:
Practice Address - Street 1:1527 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4706
Practice Address - Country:US
Practice Address - Phone:817-569-5900
Practice Address - Fax:817-569-5998
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP29812084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB160581OtherMEDICARE
TX306484201Medicaid
P01103934OtherRAILROAD MEDICARE
TX306484202OtherMEDICAID CSHCN
TX8DK337OtherBLUE CROSS BLUE SHIELD