Provider Demographics
NPI:1710019484
Name:DWYER, MELODY K (DO)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:K
Last Name:DWYER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 W FORT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4528
Mailing Address - Country:US
Mailing Address - Phone:208-377-0908
Mailing Address - Fax:208-377-2396
Practice Address - Street 1:203 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4528
Practice Address - Country:US
Practice Address - Phone:208-377-0908
Practice Address - Fax:208-377-2396
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID099174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist