Provider Demographics
NPI:1144298498
Name:DYSON, JERI ANICE (MD)
Entity type:Individual
Prefix:DR
First Name:JERI
Middle Name:ANICE
Last Name:DYSON
Suffix:
Gender:F
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP PEDIATRICS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-7260
Practice Address - Fax:904-244-4845
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94306208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA765179961AMedicaid
FL2737558-00Medicaid
FL2737558-00Medicaid
GA765179961AMedicaid