Provider Demographics
NPI:1861447153
Name:ROLLINS, DWAYNE ERIC (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:ERIC
Last Name:ROLLINS
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 1:25302 147TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2541
Mailing Address - Country:US
Mailing Address - Phone:718-978-5447
Mailing Address - Fax:718-978-8752
Practice Address - Street 1:25302 147TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2541
Practice Address - Country:US
Practice Address - Phone:718-978-5447
Practice Address - Fax:718-978-8752
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222755207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02413427Medicaid
NY02413427Medicaid
NY08012GMedicare PIN