Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 02320 | KY |
Y | 207Q00000X | Family Doctor | 02320 | KY |
N | 207QA0401X | Family Doctor - Addiction Medicine | 02320 | KY |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 02320 | KY |
NPI | 1215919451 |
---|---|
Provider Name | Mr. Jerome Anthony Dixon |
First Address | Campbellsville, KY 42718-8709 |
Second Address | Campbellsville, KY 42718-8709 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2005 |
Last Update Date | 14/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64023203 | (05) | KY |
E92006 | (02) | KY |