Provider Demographics
NPI:1366637316
Name:JOHN RICHARD DICKINSON
Entity Type:Organization
Organization Name:JOHN RICHARD DICKINSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-584-2020
Mailing Address - Street 1:28 N HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:SABINA
Mailing Address - State:OH
Mailing Address - Zip Code:45169-1150
Mailing Address - Country:US
Mailing Address - Phone:937-584-2020
Mailing Address - Fax:937-584-2080
Practice Address - Street 1:28 N HOWARD ST
Practice Address - Street 2:
Practice Address - City:SABINA
Practice Address - State:OH
Practice Address - Zip Code:45169-1150
Practice Address - Country:US
Practice Address - Phone:937-584-2020
Practice Address - Fax:937-584-2080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0199628Medicaid
OH0409400002Medicare NSC