Provider Demographics
NPI:1962420505
Name:DWYER, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:DWYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:218-333-2019
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN34382207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN783008400Medicaid
MN8HG381Medicare PIN
MN783008400Medicaid