Provider Demographics
NPI:1528506607
Name:DAWSON, JACK (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
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 1:8423 MARKET ST STE 207
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6778
Mailing Address - Country:US
Mailing Address - Phone:330-965-5490
Mailing Address - Fax:330-965-5491
Practice Address - Street 1:8423 MARKET ST STE 207
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6778
Practice Address - Country:US
Practice Address - Phone:330-965-5490
Practice Address - Fax:330-965-5491
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207240207X00000X
OH34.015892207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230609Medicaid