Provider Demographics
NPI: | 1518950898 |
---|---|
Name: | DIXON, LLOYD THEODORE (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | LLOYD |
Middle Name: | THEODORE |
Last Name: | DIXON |
Suffix: | |
Gender: | M |
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: | 4801 S CLIFF AVE STE 100 |
Mailing Address - Street 2: | DISCOVER VISION CENTERS |
Mailing Address - City: | INDEPENDENCE |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 64055-6954 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 816-478-1230 |
Mailing Address - Fax: | 816-350-4585 |
Practice Address - Street 1: | 4741 S COCHISE DR |
Practice Address - Street 2: | DISCOVER VISION CENTERS |
Practice Address - City: | INDEPENDENCE |
Practice Address - State: | MO |
Practice Address - Zip Code: | 64055 |
Practice Address - Country: | US |
Practice Address - Phone: | 816-478-1230 |
Practice Address - Fax: | 816-478-4413 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-08-23 |
Last Update Date: | 2008-05-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | T02290 | 152W00000X |
KS | 1373 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 410036663 | Other | RAILROAD MEDICARE |
4061905 | Medicare ID - Type Unspecified | ||
MO | 410036663 | Other | RAILROAD MEDICARE |