Provider Demographics
NPI:1689770315
Name:DICKSON, SCOTT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:DICKSON
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 1:311 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3125
Mailing Address - Country:US
Mailing Address - Phone:870-972-0063
Mailing Address - Fax:870-930-2914
Practice Address - Street 1:311 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3125
Practice Address - Country:US
Practice Address - Phone:870-972-0063
Practice Address - Fax:870-930-2914
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124317-069Medicaid
AR124317-069Medicaid
ARH15186Medicare UPIN