Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 6874 | MT |
NPI | 1003857111 |
---|---|
Provider Name | Charles Dixon |
First Address | Kalispell, MT 59901-3109 |
Second Address | Kalispell, MT 59901-3109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 20/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003857111 | (05) | MT |
1003857111 | BCBS (01) | MT |