Provider Demographics
NPI:1174632004
Name:WARREN, FRED DIXON (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DIXON
Last Name:WARREN
Suffix:
Gender:M
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:PO BOX 1540
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78381-1540
Mailing Address - Country:US
Mailing Address - Phone:361-729-3054
Mailing Address - Fax:361-729-5536
Practice Address - Street 1:700 E MIMOSA ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-4151
Practice Address - Country:US
Practice Address - Phone:361-729-3054
Practice Address - Fax:361-729-5536
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036119801Medicaid
TX00T954Medicare ID - Type Unspecified
TX036119801Medicaid