Provider Demographics
NPI:1376514521
Name:DICKERSON, IV, EDWARD ERNEST (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ERNEST
Last Name:DICKERSON, IV
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:PO BOX 2814
Mailing Address - Street 2:
Mailing Address - City:BRYSON CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28713-2814
Mailing Address - Country:US
Mailing Address - Phone:910-239-7600
Mailing Address - Fax:828-538-4441
Practice Address - Street 1:2053 VALLEYGATE DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3983
Practice Address - Country:US
Practice Address - Phone:910-323-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400044207YX0905X, 207Y00000X
NC94-000442082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129FPMedicaid
BD8363359OtherDEA
NC89129FPMedicaid
BD8363359OtherDEA