Provider Demographics
NPI:1245286400
Name:DIXON, MARK DALE (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALE
Last Name:DIXON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12479 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:1395 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3790
Practice Address - Country:US
Practice Address - Phone:813-972-4199
Practice Address - Fax:813-972-5753
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63074207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254054100Medicaid
FL43116OtherBCBS OF FLORIDA
FL43116TMedicare PIN
F13967Medicare UPIN
FLRAILROAD MEDICAREMedicare ID - Type UnspecifiedP00375360
FL43116OtherBCBS OF FLORIDA
FL254054100Medicaid