Provider Demographics
NPI:1013992411
Name:DAWSON, DEREK J (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:DAWSON
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 1:536 W 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2010
Mailing Address - Country:US
Mailing Address - Phone:219-836-2770
Mailing Address - Fax:219-836-0438
Practice Address - Street 1:8256 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1516
Practice Address - Country:US
Practice Address - Phone:219-836-2770
Practice Address - Fax:219-836-0438
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033635A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100215670Medicaid
IN134350Medicare ID - Type Unspecified
IN100215670Medicaid
C25456Medicare UPIN
IL563870Medicare ID - Type Unspecified