Basic Information
| Provider Information | |||||||||
| NPI: | 1184738650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAWSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | AMY | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1819 KENSINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 BROADWAY | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468021411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232682 | ||||||||
| FaxNumber: | 2604224326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01048940A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.