Provider Demographics
NPI:1457304560
Name:DICKERSON, MARIA SHIELDS (OD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:SHIELDS
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ODELL ST
Mailing Address - Street 2:
Mailing Address - City:WHITMIRE
Mailing Address - State:SC
Mailing Address - Zip Code:29178-1117
Mailing Address - Country:US
Mailing Address - Phone:803-694-4724
Mailing Address - Fax:
Practice Address - Street 1:1007 KINCAID BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-7113
Practice Address - Country:US
Practice Address - Phone:803-635-6496
Practice Address - Fax:803-635-6932
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13368Medicaid
SCAA07562803Medicare ID - Type Unspecified
SCD13368Medicaid