Provider Demographics
NPI:1497076327
Name:PIAWA, DUM LIVINUS (DO)
Entity Type:Individual
Prefix:
First Name:DUM
Middle Name:LIVINUS
Last Name:PIAWA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CENTRE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2862
Mailing Address - Country:US
Mailing Address - Phone:731-512-0104
Mailing Address - Fax:731-668-7388
Practice Address - Street 1:17 CENTRE PLAZA DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2862
Practice Address - Country:US
Practice Address - Phone:731-512-0104
Practice Address - Fax:731-668-7388
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09312200207R00000X
TN3284207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1396033379OtherNPI
TNQ028999Medicaid