Healthcare Provider Details

I. General information

NPI: 1225067135
Provider Name (Legal Business Name): DAWN D. IDOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DAWN DAVIES MD

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 CHATTANOOGA AVE
DALTON GA
30720-2637
US

IV. Provider business mailing address

PO BOX 6240
DALTON GA
30722-6240
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-2142
  • Fax: 706-226-1771
Mailing address:
  • Phone: 706-226-2142
  • Fax: 706-226-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number050891
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: