Provider Demographics
NPI:1447415229
Name:DICKERSON, RODERICK JEROME
Entity Type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:JEROME
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4033 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-2952
Mailing Address - Country:US
Mailing Address - Phone:225-357-5236
Mailing Address - Fax:
Practice Address - Street 1:4033 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-2952
Practice Address - Country:US
Practice Address - Phone:225-357-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver