Provider Demographics
NPI: | 1376538439 |
---|---|
Name: | DEHORITY, DIXON R (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DIXON |
Middle Name: | R |
Last Name: | DEHORITY |
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 60447 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28260-0447 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-384-9740 |
Mailing Address - Fax: | 704-384-9565 |
Practice Address - Street 1: | 1500 MATTHEWS TOWNSHIP PKWY |
Practice Address - Street 2: | |
Practice Address - City: | MATTHEWS |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28105-4656 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-384-9740 |
Practice Address - Fax: | 704-384-9565 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-09-15 |
Last Update Date: | 2022-11-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 34846 | 207Q00000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 8928109 | Medicaid | |
NC | 2179944E | Medicare PIN | |
NC | 2179944C | Medicare PIN | |
NC | F45126 | Medicare UPIN | |
NC | 8928109 | Medicaid |