Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1083672695 |
---|---|
Provider Name | Mr. Melvin Dixon |
First Address | Clarkston, GA 30021-2347 |
Second Address | Clarkston, GA 30021-2347 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 06/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00846513A | (05) | GA |