Provider Demographics
NPI:1659359727
Name:DWYER, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
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 1:13604 WOODSTOCK PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-7706
Mailing Address - Country:US
Mailing Address - Phone:585-245-3344
Mailing Address - Fax:
Practice Address - Street 1:13604 WOODSTOCK PL
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-7706
Practice Address - Country:US
Practice Address - Phone:585-245-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121174-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01282264Medicaid
NY121174OtherPREFERRED CARE
NY080024353Medicare PIN
NY10651HMedicare PIN
NY01282264Medicaid