Basic Information
| Provider Information | |||||||||
| NPI: | 1518920081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWAR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152616422 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 E MAIN ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136171403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868184 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 139252 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00671590 | 05 | NY | MEDICAID |