Individual
STACI E DIXON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
2120 W KEARNEY ST, SPRINGFIELD, MO 65803-1653
(417) 869-6191
(417) 869-4131
Mailing address
PO BOX 505164, SAINT LOUIS, MO 63150-5164
(417) 829-4620
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2008002406
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1962436840
—
MO
05
—
2268997
—
OH
01
—
431560263
TRICARE WEST
—
Enumeration date
07/10/2006
Last updated
10/02/2014
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