Healthcare Provider Details

I. General information

NPI: 1083811541
Provider Name (Legal Business Name): TRAVIS J DWYER D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N BANCROFT PKWY SUITE 12
WILMINGTON DE
19805-2690
US

IV. Provider business mailing address

1010 N BANCROFT PKWY SUITE 12
WILMINGTON DE
19805-2690
US

V. Phone/Fax

Practice location:
  • Phone: 302-658-1129
  • Fax: 302-658-7646
Mailing address:
  • Phone: 302-658-1129
  • Fax: 302-658-7646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006011
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP00550
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE1-0000198
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: