Provider Demographics
NPI:1366436248
Name:MULLENNIX, DIXIE R (MD)
Entity type:Individual
Prefix:DR
First Name:DIXIE
Middle Name:R
Last Name:MULLENNIX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78000
Mailing Address - Street 2:DEPT 781267
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:45278-1267
Mailing Address - Country:US
Mailing Address - Phone:937-451-3123
Mailing Address - Fax:937-350-6477
Practice Address - Street 1:5350 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-451-3123
Practice Address - Fax:937-350-6477
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-080424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4094751OtherMEDICARE PTAN
OH2328592Medicaid
OH2328592Medicaid
OHP00285707Medicare PIN
OH4094751Medicare PIN