Healthcare Provider Details

I. General information

NPI: 1962420505
Provider Name (Legal Business Name): MARK S DWYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2020
  • Fax: 218-333-2019
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number34382
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: