Provider Demographics
NPI:1710937339
Name:DIXON, ROBERT W JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:DIXON
Suffix:JR
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 1:1310 WISCONSIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2472
Mailing Address - Country:US
Mailing Address - Phone:616-846-2640
Mailing Address - Fax:616-846-3110
Practice Address - Street 1:1310 WISCONSIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2472
Practice Address - Country:US
Practice Address - Phone:616-846-2640
Practice Address - Fax:616-846-3110
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD035255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1363656Medicaid
MIRD035255OtherSTATE LICENSE
MI700311Medicare ID - Type UnspecifiedMEDICARE
MIRD035255OtherSTATE LICENSE