Provider Demographics
NPI:1164688271
Name:DWYER, MOIRA E (MD)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:E
Last Name:DWYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1316
Practice Address - Country:US
Practice Address - Phone:570-271-6328
Practice Address - Fax:570-271-6578
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451908208800000X
MN51897208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00918767OtherMEDICARE - RAIL ROAD
MN340001065Medicare UPIN
IAENROLLEDMedicaid