Provider Demographics
NPI:1720064512
Name:DYMOND, JOHN B (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:DYMOND
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 1:5767 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-2477
Mailing Address - Country:US
Mailing Address - Phone:573-480-4210
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1061052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203906508Medicaid
MO203906508Medicaid