Provider Demographics
NPI:1760097117
Name:DIXON, LAWRENCE
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:DIXON
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 1:1114 BIG SKY BLVD APT 101
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8231
Mailing Address - Country:US
Mailing Address - Phone:330-389-3136
Mailing Address - Fax:
Practice Address - Street 1:1114 BIG SKY BLVD APT 101
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-8231
Practice Address - Country:US
Practice Address - Phone:330-389-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6705691Medicaid