Provider Demographics
NPI:1346372687
Name:DICKINSON, DAVID A (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0192
Mailing Address - Country:US
Mailing Address - Phone:618-542-2146
Mailing Address - Fax:618-542-2514
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1233
Practice Address - Country:US
Practice Address - Phone:618-542-2146
Practice Address - Fax:618-542-2154
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005359213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005359OtherSTATE LICENSE