Provider Demographics
NPI:1679569412
Name:POWELL, DWIGHT ALDEN (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:ALDEN
Last Name:POWELL
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 1:555 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2654
Mailing Address - Country:US
Mailing Address - Phone:614-722-4494
Mailing Address - Fax:614-722-4458
Practice Address - Street 1:555 S 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2654
Practice Address - Country:US
Practice Address - Phone:614-722-4494
Practice Address - Fax:614-722-4458
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350432502080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64789118Medicaid
OHPO0568572OtherMEDICARE OHIO
WV010543000Medicaid
OH0398341Medicaid
C02943Medicare UPIN