Provider Demographics
NPI:1043365364
Name:DIXON, WALKER BRYAN III (MD)
Entity type:Individual
Prefix:DR
First Name:WALKER
Middle Name:BRYAN
Last Name:DIXON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SW MARLOW AVE.
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-449-5518
Mailing Address - Fax:503-223-3163
Practice Address - Street 1:1815 SW MARLOW AVE STE 112
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-449-5518
Practice Address - Fax:503-223-3163
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23069207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500627051Medicaid
ORP00924568OtherRR MEDICARE
OR286961Medicaid
ORP00924568OtherRR MEDICARE
OR286961Medicaid