Provider Demographics
NPI:1003923152
Name:DICKERSON, DONALD E (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-829-5475
Mailing Address - Fax:310-828-1359
Practice Address - Street 1:1908 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-829-5475
Practice Address - Fax:310-828-1359
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6556207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ348612Medicaid
A57558Medicare UPIN
CAZZZ348612Medicaid