Healthcare Provider Details

I. General information

NPI: 1457428682
Provider Name (Legal Business Name): BRADLEY J. DYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 GORDON DR
EXTON PA
19341-1253
US

IV. Provider business mailing address

702 GORDON DR
EXTON PA
19341-1253
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-1330
  • Fax: 610-524-8574
Mailing address:
  • Phone: 610-363-1330
  • Fax: 610-524-8574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD045611L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0013052400003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: