Provider Demographics
NPI:1174535108
Name:J. MATHIS DIXON, OD, PC
Entity type:Organization
Organization Name:J. MATHIS DIXON, OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:MATHIS
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:478-987-5500
Mailing Address - Street 1:1105 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2905
Mailing Address - Country:US
Mailing Address - Phone:478-987-5500
Mailing Address - Fax:478-988-4628
Practice Address - Street 1:1105 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2905
Practice Address - Country:US
Practice Address - Phone:478-987-5500
Practice Address - Fax:478-988-4628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 001187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I415642OtherPTAN
GA000415258BMedicaid
GA1316020001Medicare NSC