Provider Demographics
NPI:1598766313
Name:DICKERSON, TERRY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6567 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6567 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:770-997-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000890213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00869679EMedicaid
GA202833600OtherDEPARTMENT OF LABOR
GA7302184OtherAETNA
GA52811908OtherBLUE CROSS BLUE SHIELD
GA48SCCJSMedicare ID - Type Unspecified
GAU80072Medicare UPIN
GA5533180001Medicare NSC