Provider Demographics
NPI:1144341918
Name:DYER, MARC LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:LAWRENCE
Last Name:DYER
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 1:5321 CAMINO BOSQUECILLO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7116
Mailing Address - Country:US
Mailing Address - Phone:949-366-1511
Mailing Address - Fax:
Practice Address - Street 1:30131 TOWN CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2083
Practice Address - Country:US
Practice Address - Phone:949-495-2500
Practice Address - Fax:949-495-2703
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70766207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH85297Medicare UPIN