Provider Demographics
NPI:1326070590
Name:DICKERSON, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:33 E. 125TH ST.
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027
Mailing Address - Country:US
Mailing Address - Phone:212-879-5168
Mailing Address - Fax:212-879-5168
Practice Address - Street 1:324 E 112
Practice Address - Street 2:6B
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-879-5168
Practice Address - Fax:212-879-5168
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01672999Medicaid
NYC05331Medicare UPIN