=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356365043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AJAY K DHAWAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 12/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 AMBER LAKE CT
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33909-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-699-5830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2131 LONGLEAF DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46814-9555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-699-5830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301066166
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------