Healthcare Provider Details

I. General information

NPI: 1205106036
Provider Name (Legal Business Name): JOHN DIXON SMITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 02/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 SHERATON BLVD STE 100
MACON GA
31210-1359
US

IV. Provider business mailing address

275 SHERATON BLVD STE 100
MACON GA
31210-1359
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-5779
  • Fax:
Mailing address:
  • Phone: 478-745-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: