Provider Demographics
NPI:1265453047
Name:POWDERLY, JOHN DWYER II (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DWYER
Last Name:POWDERLY
Suffix:II
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:PO BOX 3547
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-3547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9801 KINCEY AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3110
Practice Address - Country:US
Practice Address - Phone:704-947-6599
Practice Address - Fax:704-947-6597
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000939207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE2701OtherMEDCOST
NC12618OtherBCBS INDIVIDUAL NUMBER
NC8912618Medicaid
NC4859724OtherCIGNA
NC7413187OtherAETNA PIN
NC203016908OtherTAX ID
NCE2701OtherMEDCOST
NC4859724OtherCIGNA
NCG92364Medicare UPIN
NC2280910DMedicare PIN