Provider Demographics
NPI:1033131073
Name:DAWALT FAMILY PRACTICE
Entity Type:Organization
Organization Name:DAWALT FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-297-5145
Mailing Address - Street 1:5645 LAFAYETTE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1102
Mailing Address - Country:US
Mailing Address - Phone:317-297-5145
Mailing Address - Fax:
Practice Address - Street 1:5645 LAFAYETTE RD
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1102
Practice Address - Country:US
Practice Address - Phone:317-297-5145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002880A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty