Basic Information
| Provider Information | |||||||||
| NPI: | 1720575632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7560 RED BUG LAKE RD STE 2048 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327656591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073668856 | ||||||||
| FaxNumber: | 4079774319 | ||||||||
| Practice Location | |||||||||
| Address1: | 7560 RED BUG LAKE RD STE 2048 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327656591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073668856 | ||||||||
| FaxNumber: | 4079774319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME143330 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 105622500 | 05 | FL | MEDICAID |