Individual
AUDREY SIMONE DAWSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
6050 STERLING CREEK RD, PORTAGE, IN 46368-7752
(219) 763-8112
(219) 764-5380
Mailing address
PO BOX 1430, PORTAGE, IN 46368-9230
(219) 763-8112
(219) 764-5380
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18004139A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
191360037
MEDICARE PTAN
IN
05
—
300021049
—
IN
Enumeration date
11/08/2018
Last updated
08/17/2020
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