Provider Demographics
NPI:1376596593
Name:DICKERSON, JOHN GRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GRAHAM
Last Name:DICKERSON
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 1:1800 DRAYTON RD STE 313
Mailing Address - Street 2:
Mailing Address - City:DRAYTON
Mailing Address - State:SC
Mailing Address - Zip Code:29333-7002
Mailing Address - Country:US
Mailing Address - Phone:864-415-1540
Mailing Address - Fax:
Practice Address - Street 1:1800 DRAYTON RD STE 313
Practice Address - Street 2:
Practice Address - City:DRAYTON
Practice Address - State:SC
Practice Address - Zip Code:29333-7002
Practice Address - Country:US
Practice Address - Phone:864-415-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00386791OtherMEDICARE RAILROAD PTAN
SC208108Medicaid
GAP00386791OtherMEDICARE RAILROAD PTAN
H32387Medicare UPIN
SC208108Medicaid
SC5878670021Medicare NSC