Provider Demographics
NPI:1801889175
Name:DIXON, DAVID RODOLPH (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RODOLPH
Last Name:DIXON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-783-6842
Practice Address - Street 1:910 WORTH ST
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4458
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-783-6842
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-00109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891344TMedicaid
NC2007582FMedicare PIN