Provider Demographics
NPI:1053889915
Name:DAWSON, AUDREY SIMONE (OD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:SIMONE
Last Name:DAWSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5380
Practice Address - Street 1:6050 STERLING CREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-7752
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-5380
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004139A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN191360037OtherMEDICARE PTAN
IN300021049Medicaid