Provider Demographics
NPI:1225067135
Name:IDOM, DAWN D (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:D
Last Name:IDOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:DAVIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6240
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-6240
Mailing Address - Country:US
Mailing Address - Phone:706-226-2142
Mailing Address - Fax:706-226-1771
Practice Address - Street 1:1436 CHATTANOOGA AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2637
Practice Address - Country:US
Practice Address - Phone:706-226-2142
Practice Address - Fax:706-226-1771
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050891207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00932324AMedicaid
GA050084341OtherRAILROAD MEDICARE
GA331239OtherWELLCARE
GACM 5659OtherRAILROAD MEDICARE GRP
GA883067OtherBLUE CROSS
GAGRP 332OtherMEDICARE GRP NUMBER
GA331239OtherWELLCARE
GA00932324AMedicaid