Provider Demographics
NPI:1497798979
Name:DIXON, PEGGY (OD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E LAUREL BLVD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2534
Mailing Address - Country:US
Mailing Address - Phone:570-628-4444
Mailing Address - Fax:570-628-3088
Practice Address - Street 1:1300 BROADCASTING RD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3220
Practice Address - Country:US
Practice Address - Phone:570-628-4444
Practice Address - Fax:610-396-9999
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1044350Medicaid
PAU33543Medicare UPIN
PA1044350Medicaid