Provider Demographics
NPI:1477557924
Name:DIXON, MICHAEL WADE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WADE
Last Name:DIXON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ERNEST W BARRETT PKWY NW
Mailing Address - Street 2:STE 62
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4918
Mailing Address - Country:US
Mailing Address - Phone:770-422-0280
Mailing Address - Fax:770-426-5388
Practice Address - Street 1:440 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:STE 62
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4918
Practice Address - Country:US
Practice Address - Phone:770-422-0280
Practice Address - Fax:770-426-5388
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000961213E00000X, 213ES0000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954643BMedicaid
GA000954643BMedicaid
GA48SCCNKMedicare ID - Type UnspecifiedMEDICARE PROVIDER #