Provider Demographics
NPI:1639102684
Name:DICKERSON, TY (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:
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 1:1842 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3414
Mailing Address - Country:US
Mailing Address - Phone:585-224-5122
Mailing Address - Fax:801-662-3664
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:PCMC, INPATIENT MEDICINE DIVISION
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6279497-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02181735Medicaid
NYRA4352Medicare ID - Type UnspecifiedEASS
NY02181735Medicaid