Provider Demographics
NPI:1457330680
Name:DAWSON, TEDD EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:TEDD
Middle Name:EUGENE
Last Name:DAWSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4304
Mailing Address - Country:US
Mailing Address - Phone:707-459-3070
Mailing Address - Fax:
Practice Address - Street 1:1196 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4304
Practice Address - Country:US
Practice Address - Phone:707-459-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38007208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36818Medicare UPIN