Provider Demographics
NPI:1447998745
Name:ALIX, DIEUSON
Entity type:Individual
Prefix:
First Name:DIEUSON
Middle Name:
Last Name:ALIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11277 SE STEVENS RD APT 301
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-4510
Mailing Address - Country:US
Mailing Address - Phone:503-278-6448
Mailing Address - Fax:
Practice Address - Street 1:11097 SE 21ST AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7640
Practice Address - Country:US
Practice Address - Phone:971-334-9295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106457175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000106457Medicaid