Provider Demographics
NPI:1467718619
Name:DICKERSON, PATRICK CALLEN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:CALLEN
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 1:1000 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8610
Mailing Address - Country:US
Mailing Address - Phone:479-271-9607
Mailing Address - Fax:479-271-2133
Practice Address - Street 1:1000 S 52ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-271-9607
Practice Address - Fax:479-271-2133
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE12109207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program