Healthcare Provider Details

I. General information

NPI: 1700855368
Provider Name (Legal Business Name): JOSEPH JOHN DAMBRAUSKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SARAH STREET LEFT FRONT
CARNEGIE PA
15106-0112
US

IV. Provider business mailing address

1005 S 6TH ST APT 15
CHAMPAIGN IL
61820-6227
US

V. Phone/Fax

Practice location:
  • Phone: 708-262-0004
  • Fax:
Mailing address:
  • Phone: 217-344-2646
  • Fax: 217-344-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number206737
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2002-0403
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD027571E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1830797
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: