Provider Demographics
NPI:1346317575
Name:DICKERSON, JEFFREY W (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:W
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4071 TATES CREEK CENTRE DR
Mailing Address - Street 2:STE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3094
Mailing Address - Country:US
Mailing Address - Phone:859-971-4695
Mailing Address - Fax:859-971-4604
Practice Address - Street 1:991 MEDICAL PARK DRIVE
Practice Address - Street 2:STE 202
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056
Practice Address - Country:US
Practice Address - Phone:606-759-8000
Practice Address - Fax:606-759-0461
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY25880207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
1210239OtherCHA
K25580OtherHUMANA
P00206691OtherMEDICARE RAILROAD
OH2473210Medicaid
000000322098OtherANTHEM
KY64258809Medicaid
P12034749OtherMULTIPLAN
000000322098OtherANTHEM
P12034749OtherMULTIPLAN