Provider Demographics
NPI:1063472892
Name:DWYER, KEVIN W (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
Last Name:DWYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-865-8251
Mailing Address - Fax:254-248-6306
Practice Address - Street 1:1507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1024
Practice Address - Country:US
Practice Address - Phone:254-865-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ19802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX300115478OtherRR/MEDICARE
TX1358483-05Medicaid
TX84198KOtherBLUE SHIELD
TX1358483-09OtherCSHCN
TX300115478OtherRR/MEDICARE
TX84198KOtherBLUE SHIELD