Provider Demographics
NPI:1558342360
Name:DIXON, LEIGH A
Entity Type:Individual
Prefix:DR
First Name:LEIGH
Middle Name:A
Last Name:DIXON
Suffix:
Gender:F
Credentials:
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 297400
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76129-0001
Mailing Address - Country:US
Mailing Address - Phone:817-257-7940
Mailing Address - Fax:817-257-7279
Practice Address - Street 1:2825 STADIUM DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1377
Practice Address - Country:US
Practice Address - Phone:817-257-7940
Practice Address - Fax:817-257-7279
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8672207Q00000X
TXN7905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807068900Medicaid
IDB4018OtherBLUE CROSS
ID000010149907OtherBLUE SHIELD
ID806110600Medicaid
ID73478OtherBLUE CROSS
IDP0019680OtherRAILROAD MEDICARE
ID000010149267OtherBLUE SHIELD
ID000010149267OtherBLUE SHIELD
ID806110600Medicaid