Provider Demographics
NPI:1487692430
Name:BROSS, DEBORAH LEA FOWLER DIXON (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEA FOWLER DIXON
Last Name:BROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:LEA
Other - Last Name:FOWLER-DIXON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:301 EDWARDSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294
Mailing Address - Country:US
Mailing Address - Phone:618-667-7057
Mailing Address - Fax:618-667-8131
Practice Address - Street 1:301 EDWARDSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294
Practice Address - Country:US
Practice Address - Phone:618-667-7057
Practice Address - Fax:618-667-8131
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091572208M00000X
IL036901572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091572Medicaid
212777Medicare ID - Type Unspecified
IL036091572Medicaid