Provider Demographics
NPI:1467638650
Name:DICKERSON, STANLEY M (OD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3528
Mailing Address - Country:US
Mailing Address - Phone:931-381-4911
Mailing Address - Fax:931-381-0966
Practice Address - Street 1:840 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3528
Practice Address - Country:US
Practice Address - Phone:931-381-4911
Practice Address - Fax:931-381-0966
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist