MEDICARE: DIXIE D RICHARDS MD

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	207N00000X	Dermatology Physician	G57309	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00062429	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G573090	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1740358464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIXIE D RICHARDS MD

Provider Business Mailing Address
First Line	:	11633 SAN VICENTE BLVD
Second Line	:	SUITE 310
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-6514
Country	:	US
Telephone Number	:	310-326-5949
Fax Number	:	310-326-6239

Provider Business Practice Location Address
First Line	:	11633 SAN VICENTE BLVD
Second Line	:	SUITE 310
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-6514
Country	:	US
Telephone Number	:	310-326-5949
Fax Number	:	310-326-6239

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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Directions to “ DIXIE D RICHARDS MD” Practice Location

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