Provider Demographics
NPI:1457431991
Name:DAWSON, JUDD WALTER (DO)
Entity Type:Individual
Prefix:
First Name:JUDD
Middle Name:WALTER
Last Name:DAWSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5154
Mailing Address - Country:US
Mailing Address - Phone:970-352-4121
Mailing Address - Fax:970-378-4315
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-352-4121
Practice Address - Fax:970-378-4315
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10757207Q00000X
CODR-46006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13600338Medicaid
COCOAAA0169Medicare PIN
COCOA105458Medicare PIN