Provider Demographics
NPI:1164160990
Name:DOTSON, JACK RYAN (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:RYAN
Last Name:DOTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-473-0637
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:940 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3505
Practice Address - Country:US
Practice Address - Phone:509-942-2516
Practice Address - Fax:509-942-2527
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAOP61458787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine