Provider Demographics
NPI:1316930605
Name:DAWSON, C R (MD)
Entity type:Individual
Prefix:DR
First Name:C
Middle Name:R
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 1:2637 KITTBUCK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-5747
Mailing Address - Country:US
Mailing Address - Phone:973-393-7756
Mailing Address - Fax:
Practice Address - Street 1:533 HARVARD CT
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1402
Practice Address - Country:US
Practice Address - Phone:973-393-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117415207R00000X
NJ25MA02852000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4004400Medicaid
NJ521129Medicare PIN
NJC09925Medicare UPIN