Provider Demographics
NPI:1861590564
Name:DIXON, GLEN A JR (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:DIXON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180
Mailing Address - Country:US
Mailing Address - Phone:781-662-7385
Mailing Address - Fax:781-662-7526
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 118
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-662-7385
Practice Address - Fax:781-662-7526
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA48679207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B73138Medicare UPIN
B40079Medicare ID - Type Unspecified