Provider Demographics
NPI:1861841033
Name:DIXON, JAIMEN L (OD)
Entity Type:Individual
Prefix:
First Name:JAIMEN
Middle Name:L
Last Name:DIXON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9261
Mailing Address - Country:US
Mailing Address - Phone:208-375-3871
Mailing Address - Fax:406-222-8419
Practice Address - Street 1:700 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9261
Practice Address - Country:US
Practice Address - Phone:208-375-3871
Practice Address - Fax:406-222-8419
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100399152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1861841033Medicaid