1215901236 NPI number — DR. DEWEY G DIXON JR. D.C.

Table of content: DR. DEWEY G DIXON JR. D.C. (NPI 1215901236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215901236 NPI number — DR. DEWEY G DIXON JR. D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
DEWEY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215901236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426 S BLANCHE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNDS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62964-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-745-6894
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 S BLANCHE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62964-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-745-6894
Provider Business Practice Location Address Fax Number:
618-745-6113
Provider Enumeration Date:
02/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  38-005019 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7782002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 131779 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".