Provider Demographics
NPI:1083649008
Name:DICKSON, DOUGLAS J (DPM)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
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 1:792 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1644
Mailing Address - Country:US
Mailing Address - Phone:315-452-4670
Mailing Address - Fax:315-579-4670
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1644
Practice Address - Country:US
Practice Address - Phone:315-452-4670
Practice Address - Fax:315-579-4670
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004816213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY620006599OtherGHI
NY01337159Medicaid
NY620006599OtherGHI
T61099Medicare UPIN
NY0910990001Medicare NSC
NY55627BMedicare PIN