Provider Demographics
NPI:1962436840
Name:DIXON, STACI E (DO)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:E
Last Name:DIXON
Suffix:
Gender:F
Credentials:DO
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 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2120 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1653
Practice Address - Country:US
Practice Address - Phone:417-869-6191
Practice Address - Fax:417-869-4131
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008002406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
MO1962436840Medicaid
OH2268997Medicaid
MO132680007Medicare PIN
OH4066298Medicare PIN
431560263OtherTRICARE WEST
MO132300040Medicare PIN