Provider Demographics
NPI:1063502615
Name:WIXTED, DENNIS D (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:D
Last Name:WIXTED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:DAMIAN
Other - Last Name:WIXTED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1745
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:828-314-4804
Practice Address - Fax:828-203-8804
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010015219Medicaid
VAC03684Medicare PIN
H92105Medicare UPIN
VA010015219Medicaid