Provider Demographics
NPI:1912980236
Name:DIXON, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E US HIGHWAY 6 STE 300
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8948
Mailing Address - Country:US
Mailing Address - Phone:219-983-6300
Mailing Address - Fax:219-983-6080
Practice Address - Street 1:85 E US HIGHWAY 6 STE 300
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8948
Practice Address - Country:US
Practice Address - Phone:219-983-6300
Practice Address - Fax:219-983-6080
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001376207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100327820Medicaid
P00386127OtherRAILROAD MEDICARE
000000497635OtherBLUE CROSS BLUE SHIELD IN
90000561OtherBLUE SHIELD OF IL
90000561OtherBLUE SHIELD OF IL
000000497635OtherBLUE CROSS BLUE SHIELD IN