1316936859 NPI number — WALTER D DIXON MD

Table of content: WALTER D DIXON MD (NPI 1316936859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316936859 NPI number — WALTER D DIXON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
WALTER
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1316936859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11828 CANON BLVD STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-2554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-599-4922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 COLISEUM DR
Provider Second Line Business Practice Location Address:
SENTARA CAREPLEX HOSPITAL
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-5963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-736-2010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2005

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: 207P00000X , with the licence number:  0101232847 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 408383100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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