Provider Demographics
NPI:1801956909
Name:DIXOPHTHAL PC
Entity type:Organization
Organization Name:DIXOPHTHAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EL-ROY
Authorized Official - Middle Name:DEC
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-439-7700
Mailing Address - Street 1:PO BOX 71445
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1445
Mailing Address - Country:US
Mailing Address - Phone:229-439-7700
Mailing Address - Fax:229-439-7283
Practice Address - Street 1:806 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2363
Practice Address - Country:US
Practice Address - Phone:229-439-7700
Practice Address - Fax:229-439-7283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040367156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000656719HMedicaid
GA000656719JMedicaid
GA000656719IMedicaid
GA18BDFLNMedicare PIN
GA000656719JMedicaid
GAG05386Medicare UPIN
GA000656719IMedicaid