Provider Demographics
NPI:1386188159
Name:DWYER, WIDMARK ROY
Entity Type:Individual
Prefix:MR
First Name:WIDMARK
Middle Name:ROY
Last Name:DWYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 UNICORN CT
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5760
Mailing Address - Country:US
Mailing Address - Phone:561-692-1925
Mailing Address - Fax:
Practice Address - Street 1:22 UNICORN CT
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5760
Practice Address - Country:US
Practice Address - Phone:561-692-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT520553726280163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health