Provider Demographics
NPI:1255651139
Name:DICKERSON, MILTON LOUIS
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:LOUIS
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 MILLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-5216
Mailing Address - Country:US
Mailing Address - Phone:901-353-1353
Mailing Address - Fax:901-353-6412
Practice Address - Street 1:3350 MILLINGTON RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-5216
Practice Address - Country:US
Practice Address - Phone:901-353-1353
Practice Address - Fax:901-353-6412
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN045131076172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver