Provider Demographics
NPI:1881620003
Name:DIXON, TYMWA DUVAL (MD)
Entity type:Individual
Prefix:
First Name:TYMWA
Middle Name:DUVAL
Last Name:DIXON
Suffix:
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 1:4700 SHREVEPORT BLANCHARD HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4702
Mailing Address - Country:US
Mailing Address - Phone:318-221-1001
Mailing Address - Fax:318-221-1044
Practice Address - Street 1:4700 SHREVEPORT BLANCHARD HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-4702
Practice Address - Country:US
Practice Address - Phone:318-221-1001
Practice Address - Fax:318-221-1044
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1482757Medicaid
LA5H322CJ83Medicare PIN
LA1482757Medicaid