Healthcare Provider Details

I. General information

NPI: 1124208210
Provider Name (Legal Business Name): MICHAEL O DIXON PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15713 HAYNES RD
LAUREL MD
20707-3303
US

IV. Provider business mailing address

15713 HAYNES RD
LAUREL MD
20707-3303
US

V. Phone/Fax

Practice location:
  • Phone: 301-717-3035
  • Fax:
Mailing address:
  • Phone: 301-717-3035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX2720
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDX2720
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDX2720
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: