Healthcare Provider Details

I. General information

NPI: 1063763522
Provider Name (Legal Business Name): BRIAN DAWSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 AMSTERDAM RD
SMITHTOWN NY
11787-3122
US

IV. Provider business mailing address

74 AMSTERDAM RD
SMITHTOWN NY
11787-3122
US

V. Phone/Fax

Practice location:
  • Phone: 646-918-4393
  • Fax:
Mailing address:
  • Phone: 646-918-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number65 006511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: