=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578750808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER STANTON DIXON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 WESTBROOK RD
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06426-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-767-1200
-----------------------------------------------------
Fax | 860-767-3031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 192 WESTBROOK RD
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06426-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-767-1200
-----------------------------------------------------
Fax | 860-767-3031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 33140
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------