Healthcare Provider Details

I. General information

NPI: 1609796440
Provider Name (Legal Business Name): DEREK DIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 MARKET ST
SAINT LOUIS MO
63103-2541
US

IV. Provider business mailing address

1717 OLIVE ST APT 628
SAINT LOUIS MO
63103-1781
US

V. Phone/Fax

Practice location:
  • Phone: 314-499-6540
  • Fax:
Mailing address:
  • Phone: 901-550-6996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: