Basic Information
Provider Information | |||||||||
NPI: | 1457345506 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIXON | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 535744 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303535510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8442945114 | ||||||||
FaxNumber: | 8656910843 | ||||||||
Practice Location | |||||||||
Address1: | 135 W RAVINE RD | ||||||||
Address2: | STE 5B | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376603847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232243460 | ||||||||
FaxNumber: | 4232243465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2005 | ||||||||
LastUpdateDate: | 04/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 21110 | TN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 050058687 | 01 |   | RR MEDICARE | OTHER | 262469 | 01 |   | ANTHEM BC/BS | OTHER | 3066808 | 01 |   | BLUE SHIELD OF TN | OTHER | 100011121 | 05 | TN |   | MEDICAID | 3073685 | 05 | TN |   | MEDICAID | 5708419 | 05 | VA |   | MEDICAID | 00013859 | 01 |   | NHC CARE ADMINISTRATORS | OTHER | TN0100 | 01 |   | JOHN DEERE | OTHER |