Healthcare Provider Details

I. General information

NPI: 1659359727
Provider Name (Legal Business Name): THOMAS J DWYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13604 WOODSTOCK PL
VALLEY CENTER CA
92082-7706
US

IV. Provider business mailing address

13604 WOODSTOCK PL
VALLEY CENTER CA
92082-7706
US

V. Phone/Fax

Practice location:
  • Phone: 585-245-3344
  • Fax:
Mailing address:
  • Phone: 585-245-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number121174-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: