Basic Information
| Provider Information | |||||||||
| NPI: | 1326336793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIKENS | ||||||||
| FirstName: | DWAYNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST BLDG SUITE303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2827 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0102204025 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04064 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.