Provider Demographics
NPI:1619065943
Name:DICKMAN, OTTO FREDERICK IV (MD)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:FREDERICK
Last Name:DICKMAN
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:EMERY MEDICAL CENTER
Mailing Address - City:CASTLE DALE
Mailing Address - State:UT
Mailing Address - Zip Code:84513-0607
Mailing Address - Country:US
Mailing Address - Phone:435-381-2305
Mailing Address - Fax:435-381-4535
Practice Address - Street 1:90 WEST MAIN
Practice Address - Street 2:EMERY MEDICAL CENTER
Practice Address - City:CASTLE DALE
Practice Address - State:UT
Practice Address - Zip Code:84513-0607
Practice Address - Country:US
Practice Address - Phone:435-381-2305
Practice Address - Fax:435-381-4535
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT495-6304-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT621762357076Medicaid
UT621762357080Medicaid
UT621762357080Medicaid
UT621762357076Medicaid