Provider Demographics
NPI:1053300400
Name:DIXON, GEORGE
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504552
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:61350
Mailing Address - Country:US
Mailing Address - Phone:913-234-1697
Mailing Address - Fax:913-234-1116
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2000
Practice Address - Fax:913-234-1116
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR38172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
MOP00467070OtherRR MEDICARE GROUP #DG5646
MO04777035OtherBCBS KCMO
KS100154530HMedicaid
MO203727607Medicaid
AR183261001Medicaid
P00852019OtherRAILROAD MEDICARE GROUP CB9013
KS100154530HMedicaid
P00852019OtherRAILROAD MEDICARE GROUP CB9013
MOY0200001Medicare PIN