1366615304 NPI number — IEON L.O. DAWSON

Table of content: (NPI 1366615304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366615304 NPI number — IEON L.O. DAWSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IEON L.O. DAWSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366615304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1257 GERSTNER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAMBRILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21054-1935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-669-5821
Provider Business Mailing Address Fax Number:
410-721-4488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 OLD BRANCH AVE
Provider Second Line Business Practice Location Address:
SUITE B205
Provider Business Practice Location Address City Name:
GAMBRILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21054-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-669-5821
Provider Business Practice Location Address Fax Number:
410-721-4488
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
CARLINE
Authorized Official Middle Name:
PAMELLA
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
202-669-5821

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 017174700 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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