Provider Demographics
NPI:1790729572
Name:DASSOW, PAUL LARRY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LARRY
Last Name:DASSOW
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:PO BOX 11023
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2023
Mailing Address - Country:US
Mailing Address - Phone:423-778-9300
Mailing Address - Fax:423-778-9301
Practice Address - Street 1:1100 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2241
Practice Address - Country:US
Practice Address - Phone:423-778-9300
Practice Address - Fax:423-778-9301
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34878207Q00000X, 207QA0000X, 207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64348782Medicaid
KY64348782Medicaid
H04392Medicare UPIN
KY0547665Medicare PIN