Provider Demographics
NPI:1417923210
Name:DWYER, KEVIN MICHAEL (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:DWYER
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:30 SHELBURNE RD
Mailing Address - Street 2:TRAUMA SERVICES
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3628
Mailing Address - Country:US
Mailing Address - Phone:203-276-7467
Mailing Address - Fax:203-276-7020
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:TRAUMA SERVICES
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-7467
Practice Address - Fax:203-276-7020
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT46891208600000X, 2086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF82861Medicare UPIN
VA004605I83Medicare ID - Type Unspecified