Provider Demographics
NPI:1932139003
Name:DIXON, THERESIA F (OD)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:F
Last Name:DIXON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E BROADWAY
Mailing Address - Street 2:MALL OF AMERICA
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-5514
Mailing Address - Country:US
Mailing Address - Phone:952-858-8414
Mailing Address - Fax:952-858-8416
Practice Address - Street 1:344 E BROADWAY
Practice Address - Street 2:MALL OF AMERICA
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-5514
Practice Address - Country:US
Practice Address - Phone:952-858-8414
Practice Address - Fax:952-858-8416
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301019800Medicaid
MN410001868Medicare ID - Type Unspecified
MN301019800Medicaid