Provider Demographics
NPI:1649560731
Name:DICKERSON, ELLIOT (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
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 1:10800 E GEDDES AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3895
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:10800 E GEDDES AVE STE 300
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-3895
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1432312085R0202X
HIMD196732085R0202X
KS04-407422085R0202X
NE305872085R0202X
CO599632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO646456OtherMEDICARE
NENA1215131OtherMEDICARE
CO646435OtherMEDICARE
CO646349OtherMEDICARE
CO646494OtherMEDICARE
CO646400OtherMEDICARE
CO646579OtherMEDICARE
CO9000159280Medicaid
KS111257116OtherMEDICARE
KS201195600AMedicaid
KSKA3249107OtherMEDICARE
NENA1214130OtherMEDICARE
NENA2517108OtherMEDICARE
CO646349OtherMEDICARE
NE$$$$$$$$$01Medicaid
CO646494OtherMEDICARE
NENA1214130OtherMEDICARE
NE$$$$$$$$$07Medicaid
KS111257116OtherMEDICARE
CO646435OtherMEDICARE
NENA1215131OtherMEDICARE
NENA2517108OtherMEDICARE