Provider Demographics
NPI:1003885120
Name:DICKSON, WALTER DALE (DPM)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:DALE
Last Name:DICKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 STATE ROUTE 288
Mailing Address - Street 2:
Mailing Address - City:ELLWOOD CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16117
Mailing Address - Country:US
Mailing Address - Phone:724-758-5564
Mailing Address - Fax:724-758-6251
Practice Address - Street 1:310 STATE ROUTE 288
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117
Practice Address - Country:US
Practice Address - Phone:724-758-5564
Practice Address - Fax:724-758-6251
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001379L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00472622OtherPALMETTO GBA - RAILROAD MEDICARE
PA048678Medicare PIN
PAP00472622OtherPALMETTO GBA - RAILROAD MEDICARE