Provider Demographics
NPI:1760472997
Name:DIXON, PHILIP LEONARD (OD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:LEONARD
Last Name:DIXON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 G ST
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654-2936
Mailing Address - Country:US
Mailing Address - Phone:559-638-8288
Mailing Address - Fax:559-638-2025
Practice Address - Street 1:1056 G ST
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2936
Practice Address - Country:US
Practice Address - Phone:559-638-8288
Practice Address - Fax:559-638-2025
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060190Medicaid
T10203Medicare UPIN
CASD0060190Medicaid