Provider Demographics
NPI:1871567073
Name:DEDWYLDER, ROSIER DAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:ROSIER
Middle Name:DAVIS
Last Name:DEDWYLDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-786-2100
Mailing Address - Fax:540-786-0677
Practice Address - Street 1:16463 DAHLGREN RD
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-5810
Practice Address - Country:US
Practice Address - Phone:540-644-9505
Practice Address - Fax:540-644-9508
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1871567073OtherCIGNA
VA1871567073Medicaid
B09212Medicare UPIN
VA1871567073Medicare PIN