Provider Demographics
NPI:1861815169
Name:DAWSON, DERRICK LAMONYE JR
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:LAMONYE
Last Name:DAWSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4571 VALLEY PKWY SE APT J
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-4942
Mailing Address - Country:US
Mailing Address - Phone:229-563-0739
Mailing Address - Fax:
Practice Address - Street 1:4571 VALLEY PKWY SE APT J
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4942
Practice Address - Country:US
Practice Address - Phone:229-563-0739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009146111N00000X
FLCH 10727111N00000X
GALD004157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered