Healthcare Provider Details

I. General information

NPI: 1780833707
Provider Name (Legal Business Name): JARED A DIXON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 MILITARY RD
BENTON AR
72015-2911
US

IV. Provider business mailing address

1304 MILITARY RD
BENTON AR
72015-2911
US

V. Phone/Fax

Practice location:
  • Phone: 501-778-0934
  • Fax: 501-778-1013
Mailing address:
  • Phone: 501-778-0934
  • Fax: 501-778-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberE7567
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE7567
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: