Healthcare Provider Details

I. General information

NPI: 1932618162
Provider Name (Legal Business Name): BRUCE MARTIN DIXON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W COLONIAL DR STE 284
OCOEE FL
34761-3432
US

IV. Provider business mailing address

10000 W COLONIAL DR STE 284
OCOEE FL
34761-3432
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-1570
  • Fax: 321-841-1569
Mailing address:
  • Phone: 321-841-1570
  • Fax: 321-841-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberOS15783
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS15783
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: