Provider Demographics
NPI:1184738650
Name:DAWSON, AMY (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DAWSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1819 KENSINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5122
Mailing Address - Country:US
Mailing Address - Phone:260-484-8435
Mailing Address - Fax:
Practice Address - Street 1:750 BROADWAY
Practice Address - Street 2:SUITE 150
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1411
Practice Address - Country:US
Practice Address - Phone:260-423-2682
Practice Address - Fax:260-422-4326
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048940A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200147090AMedicaid
IN200147090AMedicaid