Provider Demographics
NPI:1578579652
Name:DICKERSON, DIONNE SERENA (MD)
Entity Type:Individual
Prefix:
First Name:DIONNE
Middle Name:SERENA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29255 NORTHWESTERN HWY
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5741
Mailing Address - Country:US
Mailing Address - Phone:248-355-2852
Mailing Address - Fax:
Practice Address - Street 1:29255 NORTHWESTERN HWY
Practice Address - Street 2:STE 200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5741
Practice Address - Country:US
Practice Address - Phone:248-355-2852
Practice Address - Fax:248-355-2853
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074170207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4622116Medicaid
MI4622116Medicaid
MIH94871Medicare UPIN