Provider Demographics
NPI:1164521985
Name:DICKERSON, SANDRA JONES (MD)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JONES
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5695 KILRUSH CT SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5636
Mailing Address - Country:US
Mailing Address - Phone:404-578-1057
Mailing Address - Fax:
Practice Address - Street 1:5695 KILRUSH CT SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5636
Practice Address - Country:US
Practice Address - Phone:404-578-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34869207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000469675AMedicaid
GA58-1158044OtherTAX ID
GAF15341Medicare UPIN
GA000469675AMedicaid