MEDICARE: DR. BRADLEY ETHAN DWECK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	W2495	TX
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1538809090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY ETHAN DWECK MD

Provider Business Mailing Address
First Line	:	3500 GASTON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-2017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 GASTON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-2017
Country	:	US
Telephone Number	:	214-820-0111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	01/21/2026

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