Provider Demographics
NPI:1255343026
Name:MIESNER, DAWN (DO)
Entity type:Individual
Prefix:DR
First Name:DAWN
Middle Name:
Last Name:MIESNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:2512 HURST DR
Practice Address - Street 2:STE 120
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-258-5900
Practice Address - Fax:217-258-5904
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091488Medicaid
ILK29506Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036091488Medicaid
ILG54142Medicare UPIN