Provider Demographics
NPI:1699560771
Name:DIXON, MARTELL
Entity type:Individual
Prefix:
First Name:MARTELL
Middle Name:
Last Name:DIXON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1921
Mailing Address - Country:US
Mailing Address - Phone:313-832-8300
Mailing Address - Fax:313-832-3393
Practice Address - Street 1:1726 HOWARD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1921
Practice Address - Country:US
Practice Address - Phone:313-832-8300
Practice Address - Fax:313-832-3393
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker