Basic Information
| Provider Information | |||||||||
| NPI: | 1619988763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYSON | ||||||||
| FirstName: | MAYNARD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828856299 | ||||||||
| FaxNumber: | 6828851090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | H9069 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 1392667 | 01 | TX | UHC PIN | OTHER | 1485631 | 01 | TX | CIGNA PIN | OTHER | 136186712 | 05 | TX | MEDICAID | 140442845 | 05 | TX | MEDICAID | 1640370 | 01 | TX | FIRSTHEALTH PIN | OTHER | 136186714 | 05 | TX | MEDICAID | 136186715 | 01 | TX | CSHCN | OTHER | 4613484 | 01 | TX | AETNA PIN | OTHER | 62741133 | 01 | TX | MULTIPLAN PIN | OTHER | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 112070100 | 01 | TX | FIRSTCARE PIN | OTHER | 136186713 | 01 | TX | CSHCN | OTHER | 386710 | 01 | TX | GREAT WEST PIN | OTHER | 413449 | 01 | TX | PHCS PIN | OTHER | 10028696 | 01 | TX | AMERIGROUP PIN | OTHER | 109539 | 01 | TX | SUPERIOR PIN | OTHER | 89V243 | 01 | TX | BCBSTX IND PIN | OTHER |