Basic Information
Provider Information | |||||||||
NPI: | 1316106131 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAWSON | ||||||||
FirstName: | FRED | ||||||||
MiddleName: | JESTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | SUITE 112 | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8018124624 | ||||||||
FaxNumber: | 8018124699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2008 | ||||||||
LastUpdateDate: | 08/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11013885A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 41926 | AZ | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 9282119-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 915540 | 05 | AZ |   | MEDICAID |