Provider Demographics
NPI:1073695755
Name:DICKERT, JIM C (DO)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:C
Last Name:DICKERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6199 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-2679
Mailing Address - Country:US
Mailing Address - Phone:352-795-0644
Mailing Address - Fax:352-795-5950
Practice Address - Street 1:6199 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-2679
Practice Address - Country:US
Practice Address - Phone:352-795-0644
Practice Address - Fax:352-795-5950
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS1276100Medicaid
FLOS1276100Medicaid
FL82835ZMedicare ID - Type Unspecified