Provider Demographics
NPI:1902106727
Name:DIXON, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 S CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2929
Mailing Address - Country:US
Mailing Address - Phone:313-510-3961
Mailing Address - Fax:
Practice Address - Street 1:5536 S CLARENDON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2929
Practice Address - Country:US
Practice Address - Phone:313-510-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID250115108270172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver