Provider Demographics
NPI:1063473551
Name:DIXON, ETOSHA D (MD)
Entity Type:Individual
Prefix:DR
First Name:ETOSHA
Middle Name:D
Last Name:DIXON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:410-402-2379
Mailing Address - Fax:410-463-3085
Practice Address - Street 1:8800 WALTHER BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-9001
Practice Address - Country:US
Practice Address - Phone:410-882-3240
Practice Address - Fax:410-661-5093
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22045207Q00000X
MDD61785207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0123302OtherEVERCARE
9676-0039OtherCAREFIRST BCBS OF DC
MD005559001Medicaid
0056OtherCAREFIRST DC
T016-0057OtherBCBS-DC
0442052OtherEVERCARE
769698OtherBCBS
093NSE-896608-01OtherCAREFIRST BCBS OF MD
MD805701000Medicaid
093NER-896608-01OtherCAREFIRST BCBS OF MD
89660801OtherBCBS MD
0442052OtherEVERCARE
0123302OtherEVERCARE
MD005559001Medicaid
P00423576Medicare PIN
P00415863Medicare PIN