Provider Demographics
NPI:1174557086
Name:DAWSON, CLYDE (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:DAWSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:815-725-2121
Mailing Address - Fax:
Practice Address - Street 1:2100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5487
Practice Address - Country:US
Practice Address - Phone:815-725-2121
Practice Address - Fax:815-741-6303
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-063983208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36063983Medicaid
C39612Medicare UPIN
IL688000Medicare PIN
IL36063983Medicaid