Provider Demographics
NPI:1164473427
Name:DICKINSON, JOSEPH CHARLES JR (DPM)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CHARLES
Last Name:DICKINSON
Suffix:JR
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 1:1426 W ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-1714
Mailing Address - Country:US
Mailing Address - Phone:215-228-2800
Mailing Address - Fax:215-228-2050
Practice Address - Street 1:1426 W ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-1714
Practice Address - Country:US
Practice Address - Phone:215-228-2800
Practice Address - Fax:215-228-2050
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003089L213E00000X
NJMD01795213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1114015Medicaid
NJ1529501Medicaid
PA1114015Medicaid
PA512312Medicare ID - Type Unspecified
NJ080737Medicare ID - Type Unspecified
0886650001Medicare NSC