Provider Demographics
NPI:1295889111
Name:DIXON MEDICAL CLINIC,INC
Entity type:Organization
Organization Name:DIXON MEDICAL CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:225-218-0703
Mailing Address - Street 1:4730 NORTH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4016
Mailing Address - Country:US
Mailing Address - Phone:225-218-0703
Mailing Address - Fax:225-218-1155
Practice Address - Street 1:4750 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4016
Practice Address - Country:US
Practice Address - Phone:225-218-0703
Practice Address - Fax:225-218-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5BD01Medicare PIN