1457345506 NPI number — DR. MARK C DIXON MD

Table of content: GABRIEL J. ESCOBAR MD (NPI 1194804237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457345506 NPI number — DR. MARK C DIXON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
MARK
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
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:
1457345506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 535744
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-5510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-294-5114
Provider Business Mailing Address Fax Number:
865-691-0843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 W RAVINE RD
Provider Second Line Business Practice Location Address:
STE 5B
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3460
Provider Business Practice Location Address Fax Number:
423-224-3465
Provider Enumeration Date:
09/06/2005

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: 207L00000X , with the licence number:  21110 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 050058687 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 262469 . This is a "ANTHEM BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3066808 . This is a "BLUE SHIELD OF TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100011121 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3073685 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5708419 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00013859 . This is a "NHC CARE ADMINISTRATORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: TN0100 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".




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