Provider Demographics
NPI:1871627737
Name:JERRY W. DIXON, M.D., P.A.
Entity type:Organization
Organization Name:JERRY W. DIXON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-778-3361
Mailing Address - Street 1:3 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3728
Mailing Address - Country:US
Mailing Address - Phone:501-778-3361
Mailing Address - Fax:501-778-3135
Practice Address - Street 1:3 MEDICAL PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3728
Practice Address - Country:US
Practice Address - Phone:501-778-3361
Practice Address - Fax:501-778-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0176208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125732001Medicaid
ARF86661Medicare UPIN
AR125732001Medicaid