Provider Demographics
NPI:1932215464
Name:DIX, BRIAN R (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:DIX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 230A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-831-0204
Mailing Address - Fax:228-831-1868
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 230A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-0204
Practice Address - Fax:228-831-1868
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13810207LP2900X
IN02001248A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113498Medicaid
MS050000454Medicare PIN
MS050000544Medicare PIN
MSF03003Medicare UPIN