Provider Demographics
NPI:1952323131
Name:DIXON, KEVIN LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
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 1:120 SOARING EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556
Mailing Address - Country:US
Mailing Address - Phone:540-720-0407
Mailing Address - Fax:540-720-9047
Practice Address - Street 1:120 SOARING EAGLE DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556
Practice Address - Country:US
Practice Address - Phone:540-720-0407
Practice Address - Fax:540-720-9047
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9236180Medicaid
VAU66506Medicare UPIN