Provider Demographics
NPI:1255498010
Name:DIXON, HENRY CHARLES III (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:CHARLES
Last Name:DIXON
Suffix:III
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 1:8490 PICARDY AVE
Mailing Address - Street 2:BLDG 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3731
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:3401 NORTH BLVD
Practice Address - Street 2:STE 200-A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3743
Practice Address - Country:US
Practice Address - Phone:225-387-0851
Practice Address - Fax:225-383-8477
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1161683Medicaid
LA51392F809OtherMEDICARE PTAN
LAB63027Medicare UPIN
LA51392F809OtherMEDICARE PTAN
LAB63027Medicare UPIN