Provider Demographics
NPI:1538409263
Name:HERBERT K DIXON M.D. PC
Entity type:Organization
Organization Name:HERBERT K DIXON M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-624-8390
Mailing Address - Street 1:3201 MCINTOSH CIR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3647
Mailing Address - Country:US
Mailing Address - Phone:417-624-8390
Mailing Address - Fax:417-624-8392
Practice Address - Street 1:3201 MCINTOSH CIR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3647
Practice Address - Country:US
Practice Address - Phone:417-624-8390
Practice Address - Fax:417-624-8392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-16
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4915207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1760480990Medicaid