Provider Demographics
NPI:1497828479
Name:DWYER, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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 1:630 W 168TH ST # 4
Mailing Address - Street 2:VC 12TH FLOOR, SUITE 208
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158378207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01259329Medicaid
NY01259329Medicaid
NY77F982Medicare ID - Type Unspecified