Provider Demographics
NPI:1154423747
Name:DIXON, SIMON RICHARD (MBCHB)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:RICHARD
Last Name:DIXON
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:3RD FLOOR HEART CENTER
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-898-4163
Mailing Address - Fax:248-898-5596
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:3RD FLOOR HEART CENTER
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-4163
Practice Address - Fax:248-898-5596
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075071207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4446064Medicaid
MIH42974Medicare UPIN
MI4446064Medicaid