Provider Demographics
NPI:1205832953
Name:DIXON, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DIXON
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 1:700 W IRONWOOD DR
Mailing Address - Street 2:STE 101
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2666
Mailing Address - Country:US
Mailing Address - Phone:208-667-2541
Mailing Address - Fax:208-664-1173
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:STE 101
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2666
Practice Address - Country:US
Practice Address - Phone:208-667-2541
Practice Address - Fax:208-664-1173
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1111579Medicare ID - Type Unspecified
E04194Medicare UPIN