Provider Demographics
NPI:1518316702
Name:DIXON, BLAKE L (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:L
Last Name:DIXON
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 1:8970 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:AR
Mailing Address - Zip Code:72837-9110
Mailing Address - Country:US
Mailing Address - Phone:479-331-3880
Mailing Address - Fax:479-331-3788
Practice Address - Street 1:8970 MARKET ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:AR
Practice Address - Zip Code:72837-9110
Practice Address - Country:US
Practice Address - Phone:479-331-3880
Practice Address - Fax:479-331-3788
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13204207QS0010X
FLTRN23785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine