MEDICARE: MD 2 GO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1457696601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD 2 GO LLC

Provider Business Mailing Address
First Line	:	1801 SE HILLMOOR DR
Second Line	:	B109
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-7553
Country	:	US
Telephone Number	:	772-337-9473
Fax Number	:	772-337-0796

Provider Business Practice Location Address
First Line	:	1801 SE HILLMOOR DR
Second Line	:	B109
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-7553
Country	:	US
Telephone Number	:	772-337-9473
Fax Number	:	772-337-0796

Authorized Official
Title or Position	:	OWNER
Name	:	DWIGHT G DAWKINS
Credential	:	M.D.
Telephone Number	:	772-337-9473

Provider Enumeration Date	:	11/29/2012
Last Update Date	:	11/29/2012

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