Provider Demographics
NPI:1336132950
Name:DICKERSON, PATRICIA A (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
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 1:1299 E ALEX BELL RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2658
Mailing Address - Country:US
Mailing Address - Phone:937-436-1117
Mailing Address - Fax:937-436-9576
Practice Address - Street 1:1299 E ALEX BELL RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2658
Practice Address - Country:US
Practice Address - Phone:937-436-1117
Practice Address - Fax:937-436-9576
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350554000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0866648Medicaid
E95958Medicare UPIN
OH0866648Medicaid