Healthcare Provider Details

I. General information

NPI: 1215901236
Provider Name (Legal Business Name): DEWEY G DIXON JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 S BLANCHE ST
MOUNDS IL
62964-1108
US

IV. Provider business mailing address

426 S BLANCHE ST
MOUNDS IL
62964-1108
US

V. Phone/Fax

Practice location:
  • Phone: 618-745-6894
  • Fax: 618-745-6113
Mailing address:
  • Phone: 618-745-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38-005019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: