Provider Demographics
NPI:1194825935
Name:DICKERSON, DON R (MD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:R
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 1:1920 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3716
Mailing Address - Country:US
Mailing Address - Phone:307-637-5339
Mailing Address - Fax:307-637-4525
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-633-7823
Practice Address - Fax:307-633-7818
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6812A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119369400Medicaid
WY312715OtherBLUE CROSS BLUE SHIELD
WYW10136Medicare PIN
WY312715OtherBLUE CROSS BLUE SHIELD
D55493Medicare UPIN