Provider Demographics
NPI:1609040849
Name:THAXTON, DYLAN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:PAUL
Last Name:THAXTON
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 1:2223 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4700
Mailing Address - Country:US
Mailing Address - Phone:501-337-9031
Mailing Address - Fax:501-337-9033
Practice Address - Street 1:2223 GRANT ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4700
Practice Address - Country:US
Practice Address - Phone:501-337-9031
Practice Address - Fax:501-337-9033
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018509207Q00000X
ARE5683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR170953001Medicaid
MO1609040849Medicaid
KS200594090 AMedicaid
AR5H245Medicare PIN
MO1609040849Medicaid
KS200594090 AMedicaid