Provider Demographics
NPI:1598474652
Name:MWOSE, DIXON
Entity Type:Individual
Prefix:
First Name:DIXON
Middle Name:
Last Name:MWOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2724
Mailing Address - Country:US
Mailing Address - Phone:574-276-5026
Mailing Address - Fax:574-251-0869
Practice Address - Street 1:2610 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2724
Practice Address - Country:US
Practice Address - Phone:574-276-5026
Practice Address - Fax:574-251-0869
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN201371060-A171W00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN47-3518606Medicaid
IN201371060AMedicaid