Provider Demographics
NPI:1750368726
Name:SIMALA YOUNG, DAWN MARIE GAVAGAN (DO)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE GAVAGAN
Last Name:SIMALA YOUNG
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 OLDE WATERFORD WAY
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4117
Practice Address - Country:US
Practice Address - Phone:910-408-1130
Practice Address - Fax:910-408-1135
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001458207Q00000X
NC2022-02976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01609365OtherRR PTAN (MIAMI)
IN100365980Medicaid
IN000000984586OtherBCBS (MIAMI)
IN257300B (MIAMI)Medicare PIN
IN000000391357OtherBCBS
IN000000548931OtherBCBS
INF84617Medicare UPIN
IN257300BMedicare PIN