Provider Demographics
NPI:1235173899
Name:PHILLIPS, DEXTER L JR (DO)
Entity Type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:L
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6696 US HIGHWAY 20A
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515
Mailing Address - Country:US
Mailing Address - Phone:419-335-3242
Mailing Address - Fax:419-822-9008
Practice Address - Street 1:6696 US HIGHWAY 20A
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:OH
Practice Address - Zip Code:43515
Practice Address - Country:US
Practice Address - Phone:419-822-3242
Practice Address - Fax:419-822-9008
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-2700-P207P00000X, 207Q00000X
OH34-002700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00385719OtherRAILROAD MEDICARE
OH0378201Medicaid
OHE00636Medicare UPIN
OH0812773Medicare PIN
OHE00636Medicare UPIN