MEDICARE: DEZRICK OMONT DIXON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	2025-13014-01	NC

General Provider Information

NPI Number	:	1043002470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEZRICK OMONT DIXON

Provider Business Mailing Address
First Line	:	4207 ORAN AVE APT B
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-8032
Country	:	US
Telephone Number	:	919-949-3330
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 BROADWAY ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27701-2402
Country	:	US
Telephone Number	:	919-949-3330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2025
Last Update Date	:	05/21/2025

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Directions to “ DEZRICK OMONT DIXON ” Practice Location

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