Provider Demographics
NPI:1992370118
Name:DAWSON-BAGLIEN, ETHAN (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DAWSON-BAGLIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:965 WILSON RD RM A233
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-6410
Mailing Address - Country:US
Mailing Address - Phone:517-614-6138
Mailing Address - Fax:
Practice Address - Street 1:965 WILSON RD RM A233
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6410
Practice Address - Country:US
Practice Address - Phone:517-353-4362
Practice Address - Fax:517-432-0927
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51510151352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry