Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 000961 | GA |
Y | 222Z00000X | Podiatrist | 000961 | GA |
N | 2081S0010X | Sports Medicine | 000961 | GA |
N | 213ES0000X | Sports Medicine | 000961 | GA |
N | 213ES0103X | Foot & Ankle Surgery | 000961 | GA |
N | 213ES0131X | Foot Surgery | 000961 | GA |
NPI | 1477557924 |
---|---|
Provider Name | Dr. Michael Wade Dixon |
First Address | Kennesaw, GA 30144-4918 |
Second Address | Kennesaw, GA 30144-4918 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2005 |
Last Update Date | 14/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000954643B | (05) | GA |
U88000 | (02) | GA |