Provider Demographics
NPI:1215919451
Name:DIXON, JEROME ANTHONY (DO)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:ANTHONY
Last Name:DIXON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 W BEAR TRACK RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8709
Mailing Address - Country:US
Mailing Address - Phone:270-465-8133
Mailing Address - Fax:270-789-1543
Practice Address - Street 1:150 W BEAR TRACK RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-8709
Practice Address - Country:US
Practice Address - Phone:270-465-8133
Practice Address - Fax:270-789-1543
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02320204D00000X, 207QA0401X, 207QG0300X, 2083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64023203Medicaid
KY1545201Medicare PIN
KYE92006Medicare UPIN