Provider Demographics
NPI:1275656563
Name:DIXON-MARTIN, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:DIXON-MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4017 ATLANTA HWY STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-0812
Practice Address - Country:US
Practice Address - Phone:706-389-2222
Practice Address - Fax:706-389-2221
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56429208100000X, 2081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H18289Medicare UPIN