Provider Demographics
NPI:1932618162
Name:DIXON, BRUCE MARTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MARTIN
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 1:10000 W COLONIAL DR STE 284
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3432
Mailing Address - Country:US
Mailing Address - Phone:321-841-1570
Mailing Address - Fax:321-841-1569
Practice Address - Street 1:10000 W COLONIAL DR STE 284
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3432
Practice Address - Country:US
Practice Address - Phone:321-841-1570
Practice Address - Fax:321-841-1569
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15783208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118423300Medicaid