Healthcare Provider Details

I. General information

NPI: 1144594540
Provider Name (Legal Business Name): RICHARD JOHN DWANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FULTON ST
DURHAM NC
27705
US

IV. Provider business mailing address

PO BOX 52360
DURHAM NC
27717-2360
US

V. Phone/Fax

Practice location:
  • Phone: 919-286-0411
  • Fax:
Mailing address:
  • Phone: 919-932-7976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number33642
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: